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RD91  G32  1 890       The  rules  of  aseptic 

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THE    RULES 


OF 


ASEPTIC  AND  ANTISEPTIC 
SUUaERY 


A  PRACTICAL  TREATISE  FOR  THE  USE  OF  STUDENTS 
AND  THE  GENERAL  PRACTITIONER 


BY 

AEPAD   G.   GERSTEK,  M.  D. 


PROFESSOR  OF  SrEGERY  AT  THE  ^'EW  YORK  POLYCLINIC  ;   VISITING  SURGEON  TO   MOUNT  SINAI  HOSPITAL 
AND   THE   GERMAN   HOSPITAL,   NEW  YORK 


ILLUSTRATED  WITH  TWO  HUNDRED  AND  FIFTY-TWO  ENGRAVINGS 
AND   THREE  CHROMO-LITHOGRAPHIC  PLATES 


'niRD      EDITION, 


NEW  YORK 

D .     A  P  P  L  E  T  O  N    AND    COMPANY 

1891 


Copyright,  1888,  1890, 
By   D.   APPLETON  AND  COMPANY. 


RESPECTFULLY  DEDICATED 
TO  THE  FATHER  OF  ANTIPARASITIC  SURGERY^ 

Sir  JOSEPH   LISTER,   Baet. 


PREFACE   TO   THE    THIRD   EDITION. 


The  necessity  for  issuing  within  two  years  a  third  edition  of  this 
work  may  be  safely  assumed  as  a  sign  of  the  spread  of  antiseptic  doc- 
trine and  practice  among  the  members  of  the  medical  profession  in  this 
country. 

The  general  outlines  and  scope  of  the  book,  being  based  upon  the 
course  of  lectures  yearly  delivered  by  the  author  to  a  body  consisting  of 
practicing  physicians,  have  retained  their  practical  character.  Principal 
accentuation  was  placed  upon  the  points  showing  important  divergence 
from  older  methods. 

Additional  new  matter  was  introduced  in  the  chapters  on  Herniot- 
omy, Haemorrhoids,  Appendicitis,  and  the  Surgery  of  the  Kidney.  As 
in  the  former  editions,  statistical  material  was  brought  in  only  when  the 
typical  and  uniform  character  of  the  operations  pertaining  to  one  sub- 
ject permitted  its  safe  use  as  a  gauge  of  the  value  of  aseptic  or  anti- 
septic methods.  The  additional  experience  of  two  years'  work  was  util- 
ized in  widening  the  basis  of  the  conclusions  thus  drawn  from  the  com- 
putation  of  numbers. 

The  casuistic  material,  all  original  and  carefully  recorded,  forms,  in 
the  opinion  of  the  author,  the  most  valuable  part  of  the  work.  Its  quan- 
tity will  be  found  materially  increased  in  the  chapters  that  have  been  re- 
written, or  newly  introduced. 

56  East  Twenty-Fifth  Street, 

New  York,  September  8,  1890. 


PREFACE   TO   THE   FIRST   EDITION. 


The  object  of  this  volume  is  a  systematic  yet  practical  presentation 
of  the  Listerian  principle  that  has  revolutionized  surgery  within  the  last 
fifteen  years.  Its  adoption  has  wrought  so  many  incisive  changes  in 
practice,  has  shifted  the  surgeon's  standpoint  regarding  all  the  important 
disciplines  of  the  art  in  such  a  radical  manner,  that  most  English  text- 
books of  surgery,  even  those  recently  published,  have  become  partly  or 
entirely  inadequate  to  the  wants  of  the  modern  physician. 

To  a  large  number  of  medical  men  the  aseptic  and  antiseptic  methods 
present  an  incongruous  chaos  of  seemingly  contradictory  and  often  in- 
comprehensible detail,  arbitrary  and  varying,  according  to  the  predilections 
or  whims  of  this  or  that  teacher. 

Yet  the  principle  involved  is  based  on  the  correct  observation  of  a 
common  biological  process — namely,  that  of  the  decomposition  of  organic 
substances.  The  well-known  methods  employed  since  the  earliest  dawn 
of  civilization  for  the  preservation  of  organic,  especially  animal,  sub- 
stances, are  based  upon  the  empirical  yet  correct  appreciation  of  the 
causes  of  putrefaction,  and  the  practical  adaptation  of  these  methods  to 
the  healing  of  operative  or  accidental  wounds  contains  the  whole  essence 
of  the  new  surgery. 

Evils  that  former  generations  of  surgeons  deplored,  but  could  not 
effectually  combat,  such  as  septicaemia,  pyaemia,  hospital  gangrene,  and 
erysipelas,  have  been  much  abated,  as  a  direct  consequence  of  a  clear 
understanding  of  their  essential  nature  and  causation. 

Prevention  has  become  the  watchword  of  modern  practice,  and  it  can 
be  said  that,  by  the  successful  employment  of  the  preventive  methods  of 
the  present  day,  surgery  has  become  a  conservative  branch  of  the  heal- 
ing art. 


viii  PREFACE. 

Tlie  elimination  of  the  accidental  disturbances  of  repair  caused  bj 
wound  infection  has  depressed  the  percentage  of  mortality  following 
amputation  of  the  extremities  from  an  average  of  thirty-iive  per  cent  to 
about  fifteen  per  cent. 

The  dread  of  undertaking  and  submitting  to  a  surgical  operation  has 
greatly  diminished,  and  timely — that  is,  early — surgical  interference  has 
become  more  and  more  frequent,  to  the  great  advantage  of  both  p)atient 
and  physician. 

As  a  direct  consequence  of  the  implied  obligation  of  rendering  timely 
aid  where  possible,  a  laudable  eagerness  for  an  early  diagnosis  is  developed, 
and,  there  being  so  much  to  be  gained  by  diagnostic  knowledge,  thorough 
and  practical  study  of  the  morbid  processes  requiring  surgical  aid  lias 
been  greatly  stimulated. 

The  fear  of  suppuration  with  its  dreadful  consequences  does  not  stay 
now  the  hand  of  the  surgeon  as  of  old,  when  an  operation  was  always 
considered  a  forlorn  hope  and  a  last  resort.  Strangulated  herniae,  for 
instance,  are  not  allowed  to  gangrene  as  often  as  formerly,  and  herniotomy 
is  readily  resorted  to,  as  it  is  well  known  that  the  dangers  of  an  aseptic 
herniotomy  done  on  a  healthy  gut  are  diminutive  in  comparison  to  the 
certain  and  enormous  danger  of  strangulation  itself. 

By  the  conviction  that  a  fault  of  omission  may  he  followed  by  irre- 
mediable mischief,  the  sense  of  responsibility  is  stirred  up  to  vigilance, 
which  again  breeds  self-reliance  and  firmness  of  purpose  in  advising  and 
carr^ang  out  incisive  measures,  made  clearly  necessary  by  a  well-recognized 
danger  to  life  or  limb.  And  an  additional  degree  of  responsibility  is 
imposed  by  the  very  safety  of  aseptic  operations. 

It  can  not  now  be  successfully  denied  that  the  surgeon^s  acts  deter- 
mine the  fate  of  a  fresh  wound,  and  that  its  infection  and  suppuration 
are  due  to  his  technical  faults  of  omission  or  commission. 

The  principle  underlying  antiseptic  surgery  has  ceased  to  be  the 
subject  of  serious  controversy.  The  author  does  not  undertake  to  prove 
each  of  his  statements  to  the  satisfaction  of  those  who  look  but  see  not. 
His  object  is  instruction  rather  than  controversy.  Every  one  will  have 
to  pass  his  period  of  apprenticeship  with  its  l)lunders  and  lessons.  But 
he  who  becomes  a  master,  to  whom  the  primary  healing  of  a  fresh 
wound  remains  not  a  curiosity  but  becomes  a  matter  of  course,  will  not 
doubt  the  great  change  that  has  come  over  surgery. 


PREFACE. 


IX 


The  purely  practical  tendency  of  the  work  made  a  rather  free  ar- 
rangement of  the  several  parts  of  the  subject-matter  a  necessity,  or  at 
least  a  convenience;  yet  a  sufSciency  of  systematic  order  Avas  preserved 
to  give  the  collection  of  papers  the  character  of  a  well-rounded,  organic 
whole. 

The  author  begs  to  state  explicitly  that  completeness — that  is,  the 
inclusion  of  all  the  disciplines  of  surgery — was  not  aimed  at,  else  a  com- 
plete text-book  of  surgery  would  have  resulted.  The  leading  idea,  trace- 
able tlirough  all  the  matter  contained  in  the  book,  is  to  illustrate  the 
incisive  practical  changes  that  the  adoption  of  aseptic  and  antiseptic  meth- 
ods has  wrought  in  surgical  therapy.  Hereby  the  changes  in  wound 
treatment  are  meant,  as  well  as  the  notable  extension  of  active  surgery 
into  iields  formerly  considered  a  noli  me  tangere. 

As  a  consequence  of  the  stupendous  growth  of  operative  surgery  within 
the  last  decade,  a  fruitful  development  of  operative  technique  is  to  be 
noted  also.  In  accordance  with  the  desire  of  the  author  to  present  to  the 
profession  a  vivid  and  true  picture  of  contemporaneous  methods,  tlie  terms 
used  as  the  title  of  this  work  should  be  accepted  in  their  widest  signifi- 
cance. 

Confinement  to  the  meager  details  of  those  manipulations  which, 
strictly  speaking,  constitute  aseptic  and  antiseptic  measures,  would  have 
yielded  an  inadequate  and  tedious  compilation.  On  the  other  hand,  it  is 
hoped  that  the  pathological  and  technical  diversions,  introduced  for  the 
sake  of  laying  a  rational  foundation  to  the  principles  composing  the 
essence  of  antiparasitic  sm'gery,  may  be  admitted  as  germane  to  the 
subject. 

The  methods  of  wound  treatment  herein  explained  are  to  a  certain 
extent  still  undergoing  changes,  hence  should  not  be  accepted  as  final. 
Yet  it  is  undeniable  that,  as  the  clearness  of  the  comprehension  of  the 
mn^\Q  principle  of  asepticism  applied  to  wound  treatment  has  advanced, 
so  the  frequent  changes  and  bewildering  vacillation  characteristic  of  the 
ex]3erimental  stage  of  the  new  discipline  have  naturally  given  way  to 
steadier  methods.  At  present,  changes  are  not  so  frequent  as  formerly, 
yet  progress,  especially  the  conquest  of  new  fields  for  the  legitimate  prac- 
tice of  active  surgery,  is  not  at  a  standstill. 

The  author  is  well  aware  that  the  practical  directions  recommended 
by  him  are  not  the  only  ones  that  lead  to  success.     Yet,  in  the  main,  he 


X  PREFACE. 

has  refrained  from  quoting  other  authorities.  As  reasons  for  this  may  be 
adduced,  Urst,  the  disindination  to  write  a  bidky  text-book,  and,  further, 
the  knowledge  that  the  interest  of  the  reader  is  proportionate  to  the 
directness  and  immediate  character  of  the  facts  and  thoughts  contained 
in  the  work  under  perusah 

As  far  as  possible,  all  important  statements  will  be  found  borne  out  by 
illustrative  examples  taken  from  the  authors  j:)ersonal  experience. 

The  author  is  much  indebted  to  the  gentlemen  composing  the  house 
staffs  of  the  German  and  Mount  Sinai  Hospitals  for  tlie  ready  kindness 
and  courtesy  with  which  their  help  was  proffered  in  tracing  and  extract- 
ing histories  of  cases,  and  in  making  the  very  numerous  photographic 
plates  that  form  the  bulk  of  the  illustrations. 

Great  technical  difficulties,  inherent  to  the  unfavorable  season,  the 
small  space  and  inadequate  Kghting  of  the  operating-rooms  of  the  men- 
tioned hospitals,  had  to  be  overcome  in  exposing  the  sensitive  plates. 
The  matter  was  rendered  still  more  difficult  by  the  circumstance  that 
operating  and  photograpliing  were  done  by  one  and  the  same  set  of  per- 
sons, and  that  the  welfare  and  interests  of  the  patients  themselves  had 
constantly  to  be  sedulously  considered. 

In  view  of  the  defective  character  of  many  of  the  author's  negatives, 
the  greatest  praise  belongs  to  Mr.  William  Kurtz,  to  whose  artistic  taste, 
skill,  and  versatility  is  due  their  excellent  reproduction  by  phototypo- 
graphic  process. 

Proper  credit  is  given  for  the  lithographic  plates  copied  from  Rosen- 
bach,  for  the  excellent  microphotographs  reproduced  from  Koch's  classi- 
cal reports,  and  for  a  few  other  illustrations  borrowed  from  Esmarch, 
Henke,  and  Bumm. 

In  conclusion,  the  author  may  be  permitted  to  express  the  hope  that, 
by  pubHshing  his  share  of  experience  gathered  from  a  modest  public  and 
private  practice,  he  may  succeed  to  somewhat  propagate  and  popularize 
the  principles  and  practice  of  antiparasitic  surgery. 

New  York,  September  3,  1887. 


CONTENTS. 


Part  I.— ASEPSIS. 

CHAPTER  I.  PAGE 

What  are  Sepsis  and  Asepsis  ! 3 

CHAPTER  II. 

Aseptic  Wounds — Aseptic  Treatment     ...                 ......  5 

1.  General  remarks  .......         .....& 

II.  Rules  of  surgical  cleanliness         .         .         .         .                  .         .         .         -         .  7 

1.  Hands 7 

2.  The  instruments  ............  7 

3.  Wound  irrigation          ...........  7 

4.  Sponges 8 

5.  Materials  for  ligatures  and  sutures       ........  8 

6.  Drainage-tubes  and  elastic  ligatures      ........  9 

7.  Disinfecting  lotions      ...........  10 

8.  Dressings - H 

(1)  Types  of  dressings .11 

a.  Simple  exsiccation.     Bismuth,  iodoform        .         .         .         .         .         .11 

b.  Chemical  sterilization  combined  with  exsiccation.     Dry  dressings  .       12 

c.  Schede's  modification  of  the  dry  dressing,  favoring  the  organization  of 

the  moist  blood-clot 12 

d.  Simple  chemical  sterilization.     Moist  dressings     .....       13 

(2)  Preparation  of  dressings .14 

a.  Gauze  ............       14 

(a)  Corrosive-sublimate  gauze         ........       15- 

(6)  lodoformized  gauze 1& 

b.  Absorbent  cotton,  or  common  cotton  batting         .         .         .         .         .15 

c.  Sawdust 16- 

d.  Moss 17 

III.  Practical  application  of  rules       .  ........       17 

1.  In  operating         ............       17 

2.  Change  of  dressings 20- 

IV.  Aseptic  measures  in  emergencies  .........       23 

Operating  bag  and  kit  ..........       25. 

CHAPTER  m. 

Soiled  Wounds. — Antiseptic  Treatment. — Difference  between  Aseptic  and  Antiseptic 
Methods. — Illustration  of  Antiseptic  Method 27 


xn 


CONTENTS. 


CHAPTER   IV. 


Special  Rules  regauding  the  Treatment  of  Accidental  Wounds 
I.  Temporary  measures    . 
II.  Definitive  relief   . 

1.  Contaminated  wounds 

2.  Aseptic  wounds  . 

3.  Gunshot  wounds 


29 
31 
31 
34 
35 


CHAPTER   V. 


Special  Application  op  the  Aseptic  Method 
A.  General  principles    .... 
I.  Technique  of  sursical  dissection  . 
II.  Sutures        ..... 
III.  Drainage      ..... 
£.  Application  of  aseptic  method  to  diverse  organs  and 
I.  Ligatures  of  arteries  in  their  continuity 
II.  Extirpation  of  tumors 

Preservation  of  asepsis 
Safe  removal        .... 
Complete  removal 
JII.  Amputation  of  limbs    .... 

1.  Aseptics  and  antiseptics  of  amputation 

a.  Clean  cases      .... 

b.  Mildly  septic  cases  . 

c.  Septic  cases  of  greater  intensity 

2.  Hemorrhage        .... 

a.  Artificial  ana'inia     . 

b.  Ligatures  and  final  luemostasis 

3.  Securing  of  a  good  stump    . 
IV".  Operations  about  non-suppurating  joints 

1.  Puncture  and  irrigation 

2.  Arthrotomy  .... 

a.  Hydrops  genu  .... 

b.  Vegetations      .... 

c.  Floating  bodies  of  the  knee-joiat 

d.  Suturing  of  the  fractured  patella 

3.  Arthrotomy  for  irreducible  or  habitua 

fracture  .... 
V.  Operations  for  deformities   . 

1.  Knock-knee  and  bow-leg 

2.  Bony  anchylosis  in  a  vicious  position 

3.  Deformed  callus  . 

4.  Club-foot  and  pes  valgus 
VI.  Plastic  operations 

VII.  Aseptics  of  the  oral  cavity  . 
VIII.  Laryngeal  operations   . 

1.  Tracheotomy 
rt.  Superior  tracheotomy 
b.   Inferior  tracheotomy 

2.  Laryngofissure     . 

3.  Extirpation  of  the  larynx     . 


region 


dislocation,  and  for 


dcfor 


mity  due  to 


36 

36 
36 
44 

47 
48 
48 
52 
52 


01 
61 
64 
66 
67 
69 
69 
72 
74 
76 
76 
78 
78 
79 
»0 
80 

82 

86 

86 

87 

88 

88 

91 

96 

100 

100 

102 

103 

107 

108 


CONTENTS. 


Xlll 


IX.  Goitre 

X.  Amputation  of  tlie  breast 
XI.  Abdominal  operations 
1.  General  remarks 
2    Herniotomy 

a.  Herniotomy  for  strangulation 
h.  Radical  operation  for  hernia 
3.  Laparotomy 

a.  Exploratory  incision 
h.  Abdominal  tumors  . 
(«)  General  remarks 
(6)  Special  observations 
(a)  Ovarian  tumors 
(j8)  Removal  of  uterine  appendaj 
(7)  Supra-vaginal  hysterectomy 
(S)  Nephrectomy    . 

c.  Gastrostomy     . 

d.  Colotomy 
(«)  Lumbar  colotomy 
(6)  Inguinal  colotomy 
(c)  Excision  and  suture  of  gut  (enterorrhaphy) 

XII.  Hydrocele,  varicocele,  and  castration 

1.  Hydrops  of  the  tunica  vaginalis 

2.  Varicocele  ... 

3.  Castration  .         . 

XIII.  Aseptic  operations  on  the  rectum 

1.  General  observations 

2.  Haemorrhoids 

3.  Rectal  tumors 

XIV.  Aseptics  of  the  bladder 

1.  Catheterism 

2.  Litholapaxy 

3.  Cystotomy 
a.  Perineal  section 
h.  Suprapubic  section 


PAGE 
111 

113 
119 
119 
121 
123 
133 
139 
139 
140 
140 
147 
14*7 
150 
151 
153 
154 
155 
156 
156 
158 
163 
163 
164 
165 
167 
16V 
167 
171 
173 
173 
175 
177 
177 
177 


Part  II.— ANTISEPSIS. 


CHAPTER  VI. 


Natural  History  of  Idiopathic  Suppuration. — Treatment  of  Suppuration 
I.  The  cause  of  suppui-ation,  or  phlegmon 
II.  Portals  of  infection      .....,- 

1.  Infection  through  lesions  of  the  skin  . 

2.  Infection  through  lesions  of  the  mucous  membranes 

III.  Entrance,  progress,  and  localization  of  the  infection     . 

Mechanical  irritation    ...... 

Chemical  and  caloric  irritation     .... 

IV.  Development  of  phlegmon   .....         o 


183 

183 
18.fi 
185 
186 
187 
189 
190 
191 


XIV 


CONTENTS. 


V.  Spread  of  suppuration  ......„„ 

VI.  Diagnosis  and  treatment  of  phlegmon  .         .         .         ,         , 

1.  General  principles        ........ 

a.  Superficial  suppuration,  or  septic  ulcer     .... 

b.  Cutaneous  and  subcutaneous  phlegmon    .... 

c.  Deep-seated  or  subfascial  phlegmon.     Lymph-gland  abscess 

d   Acute  infectious  osteomyelitis 

e.  Chronic  suppuration  due  to  bone  necrosis.     Necrotomy    . 

2.  Phlegmonous  affections  of  some  special  regions  . 

a.  Face.     Floor  of  the  mouth.     Neck.     Temporal  and  mastoid  regions 

(«)  Face 

(b)  Neck 

(a)  Fauces  and  pliarynx  ..... 

(j8)  Submaxillary  and  parotid  cynanche 

(7)  Acute   glandular    abscesses  of   the   anterior   and    lateral    cervical 

regions  .... 

(S)  Glandular    abscesses    of    the    temporal,    mastoid,    and    occipita 

regions  .... 

b.  Mammary  and  retro-mammary  abscess 

c.  Empyema         ..... 

d.  Phlegmon  of  the  palmar  aspect  of  the  hand,  of  the  arm,  and  axilla 

e.  Suppurative  affections  of  the  lower  extremity  , 
(«)  Ingrown  toe-nail 

(b)  Chronic  ulcers  of  the  leg    . 

(c)  Acute  suppuration  of  the  prepatellary 

(d)  Acute  suppuration  of  the  knee-joint 
{c)  Suppuration  of  the  inguinal  glands 

jf.  Perityphlitic  abscess 

a.  Acute  appendicitis  (without  tumor) 
(a)  Simple  appendicitis  (no  tumor) 
{b)  Perforative  appendicitis  (no  tumor) 

b.  Acute  appendicitis  with  tumor ;  perityphlitic  abscess     . 

Types  of  acute  perityphlitic  abscess  .... 

1.  Ilio-inguinal  type  (Willard  Parker's  abscess) 

2.  Anterior  parietal  type        ..... 

3.  Posterior  parietal  type       ..... 

4.  Rectal  type        ....... 

5.  Mesocaeliac  type         ...... 

c.  Chronic  or  relapsing  apj)endicitis  and  perityphlitic  abscess 
g.  Abscess  of  the  liver         ....... 

h.  Lumbar  abscesses    ........ 

i.  Pyonephrosis,  renal  abscess,  and  calculous  kidney    . 

(a)  Nephrotomy        ........ 

(b)  Nephrectomy      ......         ^        . 

k.  Anal  abscess.     Fistula  in  ano  .         .         .         .  o 


bursa 


PAOE 

193 
198 
198 
199 
199 
203 
205 
208 
222 
2^2 
223 
225 
225 
231 


CHAPTER  VII. 


Erysipelas  and  Pskudo-Erysipelas 


289 


CONTENTS.  XV 

Part  III.— TUBERCULOSIS  : 

ITS   ASEPTIC   AND   ANTISEPTIC   TPvEATMENT. 

CHAPTER  VIII. 

PAGE 

Natural  History  and  Treatment  of  Tuberculosis 293 

I.  Etiology  of  tuberculosis.     Tubercle  bacillus         .......  293 

II.  Complication  of  tuberculosis  with  pyogenic  or  suppurative  infection     .         .         .  297 

III.  Treatment  of  tuberculosis 297 

General  principles        ...........  297 

Local  treatment  of  tuberculosis   .         .         .         .         .         .         .         .         .  298 

1.  Cutaneous  tuberculosis.     Lupus      .........  298 

2.  Tuberculosis  of  the  mucous  membranes  ........  299 

3.  Tuberculosis  of  the  lymphatic  glands,  or  scrofula  ......  299 

4.  Tuberculosis  of  tendinous  sheaths  .........  301 

5.  Tuberculosis  of  bone.     Caries.     Cold  abscess 303 

6.  Tuberculosis  of  joints.     White  swelling 305 

General  part 305 

a.  Technique  of  joint  exsection     .........  305 

(a)  Septic  injection  from  without       ........  305 

(5)  Complete  removal  of  tuberculous  tissues       ......  306 

(c)  Control  of  hsemorrhage         .........  306 

((/)  Preservation  of  function 306 

b.  After-treatment        ...........  307 

Special  part 308 

a.  Shoulder-joint 308 

b.  Elbow               310 

c.  Wrist  and  hand        ...........  314 

d.  Hip-joint          ............  315 

e.  Knee-joint        .....         ..o         ...         .  319 

/.  Ankle  and  foot  .         .         .         .         .         .         .         .         .         ,         .325 


Part  IV.-  GONORRHCEA  : 

ITS   ANTISEPTIC   TPvEATMENT. 
CHAPTER  IX. 

Natural  History  and  Treatment  of  Gonorrhcea  .         .         .        .        ,        .        .        .  331 

I.  Etiology  of  gonorrhoea.     Gonococcus    .........  331 

II.  Treatment  of  gonorrhoea 333 

1.  Acute  gonorrhoea.     Clap      ..........  383 

a.  Anterior  gonorhoeal  urethritis  .........  334 

b.  Deep-seated  gonorrhoeal  urethritis    ........  336 

2.  Chronic  gonorrhoea.     Gleet  .         .         .         .         .         .         .         .         .339 

a.  Inflammatory  stenosis  (incipient  stricture)  and  permanent  or-  cicatricial 

stricture  of  the  urethra      .........  339 

(a)  Anterior  urethra       ..........  339 

(b)  Deep  urethral  strictures 345 


xvi  CONTENTS. 

PAGE 

b.  Vegetations  of  the  urethra       .........     348 

c.  (Jranular  urethritis  ...........     348 

d.  Chronic  catarrh  of  the  posterior  part  of  the  urethra,  and  elnonic  cystitis  .     348 


Pakt  v.— syphilis  : 

ASEPTIC   AND   ANTISEPTIC    TREATMENT   OF   ITS    EXTERNAL  LESIONS. 

CHAPTER  X. 

Aseptics  and  Antiseptics  applied  to  External  Syphilitic  Lesions       ....  353 

L   Aseptic  treatment  of  primary  induration 353 

2.  Antiseptic  treatment  of  the  primary  syphilitic  ulcer 356 

a.  Chemical  sterilization  and  surface-drainage  by  medicated  moist  dressings  356 

b.  Chemical  sterilization  by  strong  caustics 357 

c.  Sterilization  by  the  actual  cautery 358 


PAET    I, 


ASEPSIS. 


CHAPTEE  I. 

WHAT  ARE  SEPSIS  AND  ASEPSIS? 

It  is  not  intended  here  to  enter  into  an  exhaustive  exposition  of  the 
essence  of  suppuration  and  the  whole  complex  of  conditions  known  under 
the  name  of  sepsis.  It  may  suffice  for  the  present  to  give  a  rough  out- 
line of  the  views  that  prevail  regarding  the  causation  of  the  conditions  in 
question. 

Albuminoid  substances,  such,  for  instance,  as  blood  or  blood-serum — 
in  fact,  all  the  tissues  of  the  dead  animal  body — will  become  putrid  under 
certain  well-known  conditions.  These  are,  first,  moisture  ;  secondly,  a  cer- 
tain temperature  called  warmth,  for  short ;  and,  thirdly,  the  presence  of 
living  organisms,  or  fungi,  named  schizomycetes,  better  known  under  the 
name  of  bacteria  and  micrococci.  If  all  these  factors  are  present,  the  ani- 
mal substance  in  question  will  ferment  or  joutrefy.  Absence  of  any  one  of 
these  factors  will  be  sufficient  to  prevent  decomposition.  To  illustrate  this 
proposition,  we  shall  mention  common  facts.  Fresh  meat  or  fish,  well 
dried,  can  be  indefinitely  preserved  ;  freezing  and,  to  a  certain  extent,  roast- 
ing will  also  prevent  its  spoiling ;  and,  lastly,  exclusion  of  micro-organisms 
by  air-tight  packing  or  sealing,  after  boiling,  will  insure  preservation  for  an 
indefinite  length  of  time. 

The  active  agents  of  decomposition  are  the  micro-organisms,  which  will 
develop  at  once  their  disintegrating  activity  as  the  conditions  favorable  to 
their  development  (moisture  and  a  certain  temperature)  are  present. 

We  then  either  thoroughly  dry  the  substance  to  be  preserved  or  jDroduce 
and  preserve  a  very  low  or  very  high  temperature  in  it,  all  of  which  will  j)re- 
vent  the  development  of  fungi.  Exclusion  of  the  fungi  is  herein  unneces- 
sary. The  third  mode  of  preservation  is  that  employed  in  canning  meats. 
They  are  first  boiled  thoroughly,  then  the  vessel  wherein  this  boiling  was 
done  is  hermetically  sealed  while  the  substance  is  still  very  hot.  Here  we 
have  a  combination  of  first  destroying  the  vitality  of  such  fungi  as  are  con- 
tained in  the  meat  before  boiling,  and,  secondly,  exclusion  of  access  of  new 
micro-organisms  to  the  sterilized  substance. 

Note. — The  most  effective  sterilizer  is  the  actual  cautery.     It  not  only  destroys  all  the  nox- 
ious germs  contained  within  the  tissues,  but  at  the  same  time  provides  these  with  an  often  dry 
and  always  hermetic  seal  against  further  infection.     If  the  eschar  and  its  vicinity  be  well  dusted 
3 


4  RULES  OF  ASEPTIC  AND  ANTISEPTIC   SURGERY. 

with  iodoform  powder,  it  will  often  happen  that  complete  cicatrization  will  take  place  beneath 
its  protection,  even  before  the  detachment  of  the  eschar. 

All  accidental  or  surgical  wound  presents  conditions  that  are  eminently 
favorable  for  the  development  of  the  fungi  in  question.  The  oozing  blood 
and  lymph,  the  bruised  and  dead  cells  of  the  various  exposed  tissues,  fur- 
nish, severed  from  their  natural  connections,  the  moist  pabulum  of  a  proper 
temperature.  The  myriads  of  particles  of  filth  or  dust,  filling  the  air  in  all 
inhabited  localities,  contain,  according  to  indubitable  evidence,  a  very  large 
proportion  of  spores  or  seeds  that,  on  falling  upon  the  wound  and  its  secre- 
tions, promptly  develop  into  fungi,  and  at  once  set  up  a  fermentative  process 
known  as  decomposition. 

The  products  of  this  fermentation  are  more  or  less  highly  poisonous  sub- 
stances— Bergmanu's  sepsin,  or  the  ptomaines  of  the  French  authors.  They 
promptlv  set  up  local  changes  in  the  shape  of  inflammation,  and  cause  sys- 
temic trouble — that  is,  septic  fever. 

It  is  further  necessary  for  us  to  know  that  in  septic  processes  of  a  wound 
not  only  the  ptomaines  are  absorbed  by  the  lymphatics,  but  that  often  an 
actual  invasion  of  the  living  tissues  by  the  fungi  will  take  place,  and  that 
the  lymphatics  and  veins  will  also  serve  as  channels  for  the  imiDortation  of 
dangerous  quantities  of  fungi  into  the  circulation.  Secondary  deposits, 
metastases,  will  then  easily  occur. 

Clinical  observers  properly  distinguish  between  different,  more  or  less 
intense  fonns  of  septic  infection,  in  which  bacteriology,  however,  does  not 
always  demonstrate  correspondingly  different  forms  of  fungi.  On  the  other 
hand,  it  is  known  that  impoverished  nutrition,  but  esiiecially  a  certain  mor- 
bid state,  namely,  diabetes  mellitus,  presents  an  extremely  favorable  con- 
dition for  the  development  of  bacterial  sepsis. 

Regarding  syphilis  and  tuberculosis,  this  can  not  be  said,  as  it  is  not 
difficult  in  these  states  to  prevent  suppuration  of  accidental  or  surgical 
wounds. 

Case. — In  1879  the  author  removed  from  the  lumbar  region  of  a  young  brewer  a 
good-sized  lipoma.  His  skin  was  covered  at  the  time  with  a  recent  syphilitic  roseola 
following  a  chancre.  Under  ordinary  antiseptic  precautions  prompt  union  by  the  first 
intention  followed,  although  the  treatment  was  altogether  ambulatory,  the  patient 
having  been  operated  on  and  treated  throughout  at  the  German  Dispensary. 

Prompt  primary  healing  of  the  wounds  caused  by  the  extirpation  of  syphilitic  buboes 
is  a  rather  common  experience  in  the  syphilitic  ward  of  the  German  Hospital. 

The  excellent  results  obtained  after  exsections  of  tuberculous  joints  are  also  proof 
positive  of  the  assertion  that  tuberculosis  in  itself  does  not  dispose  to  suppuration  and 
sepsis,  and  that  prevention  of  septic  processes  in  the  wounds  of  the  victims  of  tubercu- 
losis is  not  difficult. 

Diabetes  mellitus,  however,  does  undoubtedly  heighten  the  disposition  to  septic 
conditions.  Ordinary  antiseptic  precautions  often  fail  to  prevent  suppuration  :  hence, 
an  injury,  or  the  necessity  of  a  bloody  operation  in  a  diabetic,  should  never  be  treated 
lightly. 

It  is  the  immortal  achievement  of  Lister  to  have  first  attributed  to  fer- 


ASEPTIC  WOUNDS— ASEPTIC  TREATMENT.  5 

mentative  influences  the  disturbances  of  repair,  and  to  have  led  wound- 
treatment  into  a  rational,  hence  successful,  direction. 

Modern  wound-treatment  is  based  entirely  on  the  old  and  well-known 
principles  of  the  preservation  of  orga?iic  substances.  Of  the  several  modes 
of  preservation,  freezing  is  the  only  one  that  is  inapplicable  in  human  sur- 
gery. Exsiccation,  however,  and  burning  with  the  actual  cautery  (roast- 
ing) ;  then  chemical  sterilization  by  germicides,  and  the  combination  of 
chemical  sterilization  with  exsiccation,  contain  the  essence  of  aseptic  sur- 
gery. They  insure  wounds  against  decomposition,  and  are  a  secure  pre- 
ventive of  suppuration. 


CHAPTER  IL 

ASEPTIC   WOUNDS— ASEPTIC  TREATMENT. 
I.     GENERAL    REMARKS. 

Supposing  that  the  skin  in  the  region  to  be  operated  on  be  shaved,  then 
energetically  scrubbed  in  hot  water  with  soap  and  a  clean  brush  for  five 
minutes,  then  the  surgeon's  hands  be  scrubbed,  likewise  his  knife,  and  now 
an  incision  be  made  through  the  skin  ;  supposing  that  this  happen  in  an 
atmosphere  free  from  particles  of  dry  filth  called  dust :  such  a  wound  could 
be  safely  termed  a  clean  or  aseptic  one.  All  particles  of  filth  adhering  to 
skin,  hands,  and  instrument  were  removed  by  this  simple  process  of  scrub- 
bing, and  no  new  particles  could  settle  down  out  of  the  atmosphere,  which 
we  assumed  to  be  free  from  dust. 

Experience  has  taught  that  such  a  wound,  however  large,  will  heal 
without  suppuration,  first,  if  its  edges  be  approximated  by  sutures  made 
with  a  clean  needle  and  clean  wire,  silk,  or  gut ;  and,  secondly,  if  the  im- 
munity from  an  invasion  of  filth  be  maintained  until  the  bloody  serum 
marking  the  line  of  union  become  dry. 

But  we  can  vary  our  experiment,  and  show  that  a  wound  can  heal  with- 
out suppuration  even  if  contact  of  the  walls  of  the  same  be  imperfect  or 
none. 

Case. — Mrs.  J.  B.,  aged  forty-nine ;  branchial  cvst  of  the  submaxillary  region  of  the 
size  of  an  orange.  Had  been  punctured  a  number  of  times.  Oct.  7,  1882. — Incision  of 
six  inches  in  length;  difficult  extirpation.  The  large  vessels  of  the  neck  were  freely- 
exposed,  a  considerable  affluent  of  the  deep  jugular  vein  was  deligated.  Catgut  used  was 
rather  brittle.  Suture  and  drainage  of  the  large  wound.  Antiseptic  dressings.  Imme- 
diately after  the  operation  patient  had  a  severe  coughing  spell.  Oct.  12. — On  changing 
the  dressings  it  was  found  that  the  interior  of  the  wound  was  distended  by  a  massive 
blood-clot,  giving  an  appearance  as  though  the  tumor  had  not  been  removed  at  all. 


6  RULES   OF  ASEPTIC   AND   ANTISEPTIC  SURGERY. 

Sanguinolent  serum  was  discharging  from  the  drainage-tuhe.  Dressings  renewed. 
Oct.  16. — Tumor  much  diminished  in  size.  Drainage-tube  removed.  Oct.  20. — 
Wound  firmly  liealed;  outline  of  neck  iioniial.     Throughout,  normal  temperatures. 

Here  we  see  that  undoubtedly  secondary  venous  haemorrhage  had  taken 
place  into  the  large  cavity  of  the  wound.  The  distention  did  not  reach  a 
sufficient  degree  to  jH-oduce  a  rupture  of  the  line  of  sutures.  The  enormous 
clot  was  rapidly  absorbed,  and  the  wound  healed  without  suppuration, 
though  not  by  primary  adhesion.  If  the  wound  had  not  been  aseptic, 
putrefaction  of  the  clot  and  dangerous  septic  processes  would  have  inevit- 
ably followed. 

Still  more  curious  is  the  course  of  an  aseptic  wound  that  is  not  united 
at  all,  but  is  left  gaping,  provided  that  suitable  means  are  emj^loyed  to 
preserve  its  aseptic  character. 

Case. — Mrs.  C.  T..  aged  forty-three,  came  from  Ohio  to  have  a  syphilitic  defect  of  the 
nose  repaired.  Total  rhinoplasty,  Sept.  18,  1883,  at  Mount  Sinai  Hospital.  A  suitable 
flap  containing  the  periosteum  was  raised  from  the  forehead.  The  edges  of  the  frontal 
wound  could  not  be  drawn  together,  therefore  a  properly  shaped,  well-disinfected 
piece  of  rubber  tissue  was  laid  on  it,  and  this  was  covered  with  an  iodoform  dressing. 
Sept.  23. — Stitches  removed  from  nasal  sutures.  Dressing  on  forehead  dry,  therefore 
it  was  left  undisturbed.  Oct.  1. — Dressing  of  frontal  wound  being  removed,  the  rubber- 
tissue  covering  became  visible ;  after  this  was  taken  away  the  edges  of  the  wound 
were  found  to  be  cicatrized  to  the  width  of  half  an  inch  on  both  sides.  A  moist, 
fresh-looking  remnant  of  tlie  blood-clot  was  still  covering  a  strip  of  the  middle  of  the 
wound.  No  suppuration  whatever.  Dressings  renewed.  Oct.  6. — Entire  wound 
cicatrized  with  the  exception  of  a  spot  as  large  as  a  penny  at  the  upper  end.  Oct.  10. 
— Discharged  cured. 

Here,  then,  is  an  example  of  the  now  commonly  observed  fact  that  a 
gaining  defect  will  cicatrize  over  without  suppuration  if  putrefactive  changes 
be  excluded  from  the  clot  filling  up  the  gap.  This  observation  involves  a 
radical  difference  from  the  old  tenet  that  whatever  wound  does  not  heal 
by  primary  adhesion  must  heal  by  suppuration.  A  third  possibility  has 
become  demonstrable,  for  which  older  pathology  had  no  explanation. 

It  is  necessary  to  state  that  in  both  of  the  latter  examples  the  condition 
of  a  dustless  atmosphere  during  the  time  of  the  operation  was  not  present ; 
the  operations  were  done  in  ordinary  rooms,  openly  communicating  with 
the  dusty  streets  of  Xew  York,  yet  the  behavior  of  the  wounds  was  per- 
fectly correct. 

The  extreme  difficulty  of  preparing  and  maintaining  a  dustless  atmos- 
phere in  a  room  of  an  inhabited  locality  is  well  known  to  everybody,  and, 
as  a  matter  of  fact,  the  general  practitioner  must  and  will  have  to  do  his 
surgery  in  more  or  less  dusty  rooms.  Since  the  procurement  of  this  con- 
dition is  practically  unattainable,  frequent  irrigation  or  rinsing  of  the 
wound  becomes  a  necessity.  But  even  a  constant  and  powerful  stream  of 
fluids  will  not  be  able  to  dislodge  all  the  particles  of  dust  that  may  have 
settled  down  upon  and  insinuated  themselves  into  the  nooks  and  crevices 


ASEPTIC  WOUNDS— ASEPTIC  TREATMENT.  7 

of  a  wound.  Hence  it  is  desirable  to  employ  a  liquid  that,  aside  from  its 
non-irritant  quality,  will  have  the  property  of  extinguishiug  the  noxious 
effects  of  those  particles  of  dust  that  can  not  be  washed  away  by  the  irriga- 
tion, but  remain  imbedded  in  the  tissues.      This  is  cliemical  sterilization. 

Different  disinfecting  solutions  are  used  for  this  purpose  to  answer  vari- 
ous requirements.     Their  composition  and  uses  will  be  mentioned  hereafter. 

Note. — Kiimmel,  of  Hamburg,  has  shoTvn  that  a  dustless  operating-room  can  be  had  in  a 
well-appointed  hospital,  and  Neuber,  of  Kiel,  has  excellent  results  from  operations  done  in  such 
a  dustless  room,  with  well-cleansed  hands,  apparatus,  and  instruments,  without  the  employment 
of  antiseptic  fluids.  Even  the  dressings  used  are  not  impregnated  with  any  antiseptic  chemical, 
but  are  merely  "  sterilized  "  by  being  exposed  to  dry  heat.  No  sponges  are  used,  all  blood 
being  removed  with  a  sterilized  solution  of  common  salt  (6  :  1,000),  which  is  absolutely  unirritat- 
ing,  and  certainly  forms  the  most  gentle  manner  of  cleansing  a  wound. 

n.     RULES   OF    SURGICAL   CLEANLINESS. 

1.  Hands. — The  hands  and  forearms,  especiallij  the  finger-nails,  of  the 
surgeon  and  his  assistants  should  be  well  scrubbed  in  hot  water  with  soap 
and  brush  for  five  minutes  ;  likewise  the  region  of  the  body  of  the  j)atient 
to  be  operated  on  after  carefully  shaving  off  the  hair.  After  this  follows  an 
immersion  of  the  hands  in  alcohol,  and  then  in  corrosive  sublimate  lotion 
(1  : 1,000)  for  one  minute. 

Note  1. — Kiimmel's  recommendation  of  green  soap  (potash  or  soft  soap)  is  excellent,  on  ac- 
count of  its  great  solvent  properties. 

Note  2. — Rings,  especially  those  having  stone  settings,  should  never  be  worn  by  the  surgeon 
or  his  aids  in  an  operation.  Bangles  and  bracelets  of  female  nurses  should  not  be  tolerated. 
Every  one's  arms  should  be  bared  and  scrubbed  to  the  elbows. 

2.  Tie  instruments  should  be  subjected  to  a  careful  and  minute  cleans- 
ing with  soap  and  brush,  especial  care  being  taken  to  remove  dry  jDarticles 
of  blood,  pus,  etc.,  from  the  grooves  and  behind  the  clasps  of  the  more  com- 
jiosite  instruments,  which  ought  to  be  taken  apart  each  time  for  cleansing. 
Hollow  instruments  (trocars),  or  those  that  can  not  be  taken  apart,  should 
be  boiled  in  water  for  thirty  minutes.  They  should  be  immersed  for  ten 
minutes  in  a  three-per-cent  solution  of  carbolic  acid  before  use. 

Note. — The  surgeon  should  learn  to  get  along  with  as  few  instruments  as  possible.  In 
selecting  instruments,  preference  should  be  given  to  the  most  simple.  The  best  instruments  are 
those  having  smooth  and  well-polished  surfaces  ;  grooved  or  roughened  handles  are  hard  to  clean, 
and  unnecessary. 

3.  Wound  Irrigation. — During  the  operation  the  wound  should  be  fre- 
quently irrigated  with  the  proper  kind  of  a  disinfecting  fluid  ;  the  hands 
of  the  surgeon  and  his  assistants  should  be  also  washed  at  not  too  long 
intervals  in  a  disinfecting  fluid  (corrosive  sublimate,  1  : 1,000)  ;  the  instru- 
ments should  be  kept  immersed  in  a  three-per-cent  solution  of  carbolic 
acid  (which  is  the  least  injurious  to  them).  The  most  convenient  form  of 
irrigator  is  the  well-known  '^'fountain  syringe"  of  vulcanized  rubber. 

Note. — Whenever  any  one  of  those  engaged  at  an  operation  touches  a  not  disinfected  object 
— hands  a  chair,  opens  the  window  or  door,  helps  the  angesthetizer  during  a  vomiting  spell  of  the 


8  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

patient,  scratches  his  face,  or  wipes  his  nose — it  is  absolutdy  necessary  that  his  hands  be  scrubbed 
and  disinfected  anew.  Instruments  that  are  accidentally  dropped  should  be  left  untouched.  Raw 
assistants,  and  especially  nurses,  male  and  female,  trained  or  untrained,  should  be  earnestly  in- 
structed beforehand,  and  constantly  watched  afterward,  regarding  this  all-important  discipline. 

4.  Sponges  should  be  beaten  free  from  calcareous  particles,  then  im- 
mersed for  fifteen  minutes  in  dilute  muriatic  acid  to  dissolve  the  remnant 
of  lime,  washed  in  cold  water,  then  thoroughly  kneaded  by  hand  with  green 
soap  in  hot  water  for  five  minutes,  rinsed,  and  then  immersed  in  a  five-per- 
cent solution  of  carbolic  acid,  in  which  they  remain  until  required  for  use. 
Sponges  used  once  in  an  aseptic  operation  can  be  used  again.  Careful  wash- 
ing out  with  green  soap  and  hot  water  of  all  the  remnants  of  fibrin  and 
blood,  then  immersion  in  a  five-per-cent  solution  of  carbolic  acid,  are  suffi- 
cient. It  is  not  good  to  use  too  many  sponges  at  an  operation.  When  sat- 
urated with  blood  at  an  operation,  they  should  be  washed  free  from  it  in 
tepid  ivoter,  then  thrown  into  a  basin  filled  with  carbolic  solution,  and  hence 
handed  to  the  surgeon.  Carbolic  acid  is  preferable  for  preservation  of 
sponges  until  use,  because  it  does  not  become  decomposed  and  inert,  as,  for 
instance,  corrosive  sublimate. 

Note. — Selected  Florida  sponges  are  cheap  and  good.  In  New  York  a  pound  can  be  bought 
for  about  two  dollars,  each  sponge  costing  on  an  average  two  cents. 

5.  Materials  for  Ligatures  and  Sutures. — Well-prepared  catgut  of  differ- 
ent thicknesses  will  answer  every  purpose  for  ligatures  and  sutures.  The 
finest  suture  work  on  the  intestines  can  be  neatly  and  reliably  done  with 
catgut  No.  0.  The  most  massive  pedicle  can  be  safely  tied  with  catgut  No. 
4.  For  ordinary  ligatures  and  sutures  No.  1  will  be  most  convenient,  and 
should  constitute  the  bulk  of  the  surgeon's  supply. 

The  simplest  way  of  preparing  catgut  is  Kocher's  :  Wash  in  ether,  then 
immerse  catgut  for  twenty-four  hours  in  good  oil  of  Juniijcr  (ol.  juniperi 
baccarum,  oil  of  the  berry,  not  the  oil  gained  from  the  wood)  ;  transfer  into 
and  preserve  in  absolute  alcohol  1,000^  corrosive  sublimate  1,  until  use. 
Alcohol  keeps  catgut  hard  and  firm,  yet  flexible.  Where  it  is  desirable  to 
prevent  too  early  absorption,  as,  for  instance,  in  intestinal  sutures,  a  hard- 
ening process  should  be  added  to  the  disinfection.  After  disinfection  the 
article  should  be  washed  in  alcohol,  then  placed  into  a  quart  of  a  five-per- 
cent solution  of  carbolic  acid  containing  thirty  grains  of  bichi-omate  of 
potash.  Forty-eight  hours'  immersion  will  produce  catgut  that  will  resist 
the  action  of  the  living  tissues  for  a  week  or  longer.  Large-sized  catgut 
needs  a  longer  immersion.     Wind  up  on  bobbins. 

Note  1. — Good  catgut  can  be  procured  from  L.  H.  Keller  &  Co.,  64  Nassau  Street,  New 
York,  for  a  moderate  price.  Dry  preservation  makes  catgut  more  suitable  for  transportation : 
Immerse  the  prepared  article  for  five  minutes  in  ether,  100  ;  iodoform,  .5.  Take  out  and  place  in 
a  well-corked,  wide-mouthed  bottle.     A  film  of  iodoform  will  cover  each  thread. 

Note  2. — The  author  observed  once  unmistakable  wound  infection  by  improperly  kept  catgut. 
Case. — Jenny  Marks,  servant-girl,  aged  twenty,  admitted  November  10,  1883,  to  Mount  Sinai 
Hospital  with  habitual  subcoracoid  dislocation  of  the  right  shoulder-joint.  "  Sprain  "  had  been 
diagnosticated  by  a  physician,  seven  weeks  previous  to  her  admission,  who  ordered  a  liniment. 
On  admission,  reduction  was  easily  effected  by  manipulation,  but  the  weight  of  the  limb  was  suf- 


ASEPTIC  WOUNDS— ASEPTIC  TREATMENT.  9 

fieient  to  reproduce  the  dislocation.  A  plaster-of-Paris  jacket,  inclosing  the  reduced  arm,  was 
applied  and  worn  for  four  weeks  without  any  effect.  Dec.  11th. — The  joint  was  freely  opened 
by  an  anterior  longitudinal  incision,  when  it  became  evident  that  the  tendency  to  dislocation  was 
due  to  laxity  or  redundancy  of  the  anterior  part  of  the  capsular  ligament.  By  two  semi-ellipti- 
cal incisions,  a  piece  of  the  capsule  one  inch  long  and  half  an  inch  in  width  was  removed.  The 
capsular  as  well  as  the  muscular  and  the  skin  wound  were  united  by  three  tiers  of  interrupted 
catgut  sutures,  a  drainage-tube  having  previously  been  carried  just  within  the  capsule.  The 
next  day  moderate  fever  (101°  Fahr.),  but  great  dejection,  headache,  and  vomiting  were  observed, 
the  patient  complaining  of  much  pain  in  the  joint.  Dec.  13th. — The  thermometer  indicated  103° 
Fahr.,  with  a  corresponding  increase  of  the  general  disturbance.  The  patient  was  aneesthetized, 
and  the  wound  was  exposed.  No  redness,  only  slight  oedema  was  visible.  The  wound  was  re- 
opened. Firm  agglutination  was  present  everywhere  except  in  four  places,  where  swollen,  dis- 
colored ligatures  applied  to  the  circumflex  artery  and  some  smaller  vessels  were  seen  surrounded 
by  a  halo  of  yellowish,  semi-fluid,  broken-down  tissue,  evidently  representing  small  abscesses 
that  were  forming  about  the  catgut  ligatures.  They  were  removed,  the  wound  was  irrigated  with 
carbolic  lotion,  and  packed  with  gauze.  The  fever  fell  off  at  once,  and  no  further  complication 
interrupted  the  course  of  healing.     The  habitual  luxation  was  also  cured. 

SilJc  and  common  cotton  or  linen  thread  can  be  rendered  unirritant 
either  by  boiling  it  for  an  hour  in  a  five-per-cent  solution  of  carbolic  acid 
(Czerny)  or  by  immersion  during  twenty-four  hours  in  a  solution  of  alcohol 
100,  corrosive  sublimate  1,  then  preserving  in  alcobol. 

Silk-worm  gut  is  excellent  material  for  suturing.  It  is  prepared  like 
silk,  and  before  use  should  be  soaked  awhile  in  carbolic  lotion  to  make  it 
supple.     Its  advantage  :  it  is  easy  to  thread. 

6.  Drainage-tubes  and  elastic  ligatures  are  cut  into  proper  lengths — that 
is,  a  little  shorter  than  the  height  of  the  wide-mouthed  bottle  in  which  they 
are  kept.  This  is  filled  with  a  five-per-cent  solution  of  carbolic  acid,  that 
should  be  renewed  from  time  to  time.  The  tubes  will  always  occupy  an 
upright  230sition  in  the  bottle,  and  can  be  taken  out  easily. 

Note. — Rubber  tubing  of  black  material  is  preferable  to  the  coarser  and  unyielding  white 
stuff,  on  account  of  its  softness  and  pliability. 

Theoretically  speaking,  a  iderfectly  aseptic  wound  does  not  require  any 
drainage.  If  the  secretions  following  an  operation  or  injury  do  not  contain 
anything  that  is  capable  of  inducing  putrid  changes,  they  will  be  absorbed, 
and  will  not  cause  any  disturbance  in  the  wound  or  the  general  health.  The 
large  blood-clot  around  a  fractured  bone  is  harmlessly  absorbed ;  a  large 
blood-clot  in  an  aseptic  operation  wound  will  be  also  absorbed  without  local 
or  general  disturbance,  as  Mrs.  B.'s  case  (see  page  5)  has  shown.  The  expe- 
rienced surgeon  who  has  mastered  the  technique  of  asepticism  will  not  hesi- 
tate to  close  up  without  drainage  a  small  wound,  as,  for  instance,  after 
deligating  the  subclavian  or  iliac  arteries.  But,  in  operations  where  large 
surfaces  were  long  exposed,  and  Avhere  the  wound  is  very  irregular,  the  pos- 
sibility of  a  however  slight  and  unavoidable  contamination  should  always 
be  kept  in  view.  Vents  should  therefore  be  provided  in  the  shape  of  prop- 
erly placed  drainage-tubes  for  the  easy  egress  of  secretions,  possibly  contain- 
ing elements  of  future  decomposition.  If  the  healing  be  prompt,  the  tubes 
can  be  withdrawn  on  the  third,  fourth,  or  sixth  day.  In  case  of  suppura- 
tion, bland  or  destructive,  they  will  be  in  place  and  very  opportune. 


10  RULES  OF   ASEPTIC  AND  ANTISEPTIC  SURGERY. 

7.  Disinfecting  Lotions. — With  a  few  exceptions  (very  large  wounds  re- 
quiring prolonged  irrigation,  and  in  operations  involving  the  peritoneum),  two 
lotions  will  be  found  sufficient.  For  the  immersion  of  the  instruments,  a  three- 
per-cent  solution  of  carbolic  acid,  and  for  the  irrigation  and  disinfection  of 
hands  and  skin,  a  solution  of  corrosive  sublimate  of  1  :  1,000 — 1,500. 

Note. — The  almost  exclusive  use  by  the  author  of  carbolic  acid  and  corrosive  sublimate 
as  germicides  is  intentional.  It  was  determined  by  the  fact  that  these  substances  are,  first, 
thoroujrhly  reliable  and  highly  effective ;  secondly,  procurable  almost  everywhere,  in  the  country 
store  as  well  as  in  the  city ;  thirdly,  because  adherence  to  certain  carefully  selected  substances 
results  in  a  thorough  knowledge  of  their  proper  use  under  varying  conditions. 

Boiled  water  is  preferable  as  a  solvent.  It  alone  would  be  sufficient  if 
we  were  absolutely  sure  against  the  introduction  of  filth  into  the  wound. 

Note. — A  ready  and  handy  way  of  mixing  the  lotions  is  the  following  one: 
Carbolic  Acid. — One  tablespoonful  or  four  teaspoonfuls  to  a  "  quart  bottle  "  of  hot  water 
will  make  a  lotion  of  the  strength  of  about  three  per  cent,  reckoning  650  grammes  to  the  ordinary 
wine-bottle,  erroneously  called  a  "  quart  bottle." 

Corrosive  Sublimate. — Keep  on  hand  a  few  ounces  of  an  alcoholic  solution  of  the  salt  of  1 :  10 
in  a  glass-stoppered  bottle  (in  boxwood  case  for  transportation).  One  teaspoonful  of  this  added 
to  a  quart  bottle  of  hot  water  will  make  about  a  1 : 1,500  solution,  which  can  be  weakened  by 
dilution.  The  addition  of  one  teaspoonful  of  cooking  salt  will  prevent  disintegration  of  the  mer- 
curic preparation. 

Boro- Salicylic  Lotion.— In  cases  where  carbolic  or  mercurial  poisoning 
could  be  produced  by  the  use  of  mercuric  or  carbolic  irrigation,  Thiersch's 
solution  is  commendable  as  a  substitute.  It  consists  of  salicylic  acid  2, 
boric  acid  12,  and  hot  water  1,000  parts.  It  is  non-poisonous,  very  bland, 
and  the  peritoneum  can  be  washed  with  it  with  impunity.  External  wounds 
of  large  size  should  be  also  irrigated  with  this  lotion.  A  final  thorough  irri- 
gation with  corrosive  sublimate  should  sterilize  the  wound  before  closing  it. 

Creoline  Emulsion. — Somewhat  more  convenient  than  Thiersch's  solu- 
tion is  a  mixture  of  creoline  with  water  in  the  proportion  of  from  one  half 
to  two  per  cent.  It  is  also  non-poisonous,  and  does  not  irritate  the  skin  or 
corrode  instruments. 

Note. — The  selection  of  different  lotions  should  be  governed  by  the  following  experiences : 
Carbolic  lotions  are  dangerous  to  small  cJdldren,  even  in  great  dilution,  and  should  never  be  used 
on  them.  Corrosive  sublimate  is  also  poisonous,  causing  saUvation  and  occasionally  fatal  diph- 
theritic inflammation  of  the  ileum  and  the  thick  gut,  if  its  use  is  immoderate.  Wherever  super- 
ficial ulcers  or  inflammations  of  the  cutis  require  the  antiphlogistic  action  of  the  very  diffusible 
carbolic  lotion,  it  should  be  employed  in  the  strength  of  two  or  three  per  cent.  The  continued 
use  of  higher  concentrations  will  corrode  the  tissues,  and  is  otherwise  dangerous. 

Where  a  direct  application  of  the  lotion  to  the  wounded  or  diseased  surface  is  desirable,  as, 
for  instance,  in  all  bloody  operations,  mercuric  bichloride  deserves  the  preference  over  carbolic 
acid.  Even  weak  solutions  (as  1 :  5,000)  have  a  decided  germicidal  power,  and  can  be  used  on 
very  extensive  wounds  for  hours  without  serious  danger  of  intoxication.  The  final  irrigation  of 
an  operation  wound  should  always  be  done  with  a  stronger  ^^1  :  1,000)  solution.  Abscess  cavities 
will  always  require  the  stronger  solutions. 

The  greatest  advantage  of  corrosive  sublimate  over  carbolic  acid  is,  however,  to  be  sought  in 
its  different  effect  upon  the  fresh  blood-clot  and  the  tissues  exposed  to  its  action  in  a  fresh  wound. 
It  will  be  seen  that  irrigating  an  amputation  wound,  for  instance,  with  carbolic  lotion,  will  each 
time  provoke  very  profuse  oozing.    Vessels  that  had  stopped  bleeding  by  the  formation  of  a  clot 


ASEPTIC  WOUNDS— ASEPTIC   TREATMENT.  H 

within  their  cut  orifices  begin  to  bleed  anew  after  carbolic  irrigation.  This  is  caused  by  the 
peculiar  macerating  effect  of  carbolic  acid  upon  the  fresh  blood-clot.  Its  color  turns  from  dark 
red  to  a  light  brick-red,  its  toughness  and  cohesion  are  lost,  and  the  slightest  touch  of  a  sponge 
will  suffice  to  detach  it  from  the  orifice  of  cut  vessels,  thus  renewing  the  hsemorrhage.  Another 
disagreeable  effect  of  carbolic  lotions  upon  wounds  is  the  profuse  discharge  of  bloody  serum 
continuing  for  one  or  two  days  after  the  operation,  rendering  one  or  more  changes  of  dressings 
necessary  within  a  day  or  two,  and  thus  depriving  the  wound  of  needed  rest  at  the  most  critical 
period  of  repair. 

Corrosive  sublimate  does  not  dissolve  clots,  hence  oozing  stops  by  natural  means  during  its 
use.  It  does  not  irritate  the  vaso-motor  nerves  as  carbolic  acid  seems  to  do,  hence  the  oozing 
subseciuent  upon  an  operation  done  with  its  aid  is  very  scanty.  Drainage  is  easier,  can  often  be 
altogether  spared ;  no  early  change  of  dressings  is  required,  and  cure  under  one  dressing  is  possi- 
ble, and,  in  fact,  is  the  rule  after  its  proper  use. 

8.  Dressing's. — We  have  mentioned  that  there  are  two  ways  of  preserving 
the  aseptic  character  of  a  wound,  viz.,  by  exsiccation  or  by  sterilization  of 
the  secretions.     These  two  methods  can  also  be  advantageously  combined. 


(1)    Types  of  Dressings. 

a.  Simple  Exsiccatiox. — Small,  or  comparatively  small  wounds,  ad- 
mitting of  an  exact  coaptation  of  the  deeper  as  well  as  their  superficial 
parts  by  suture,  are  exquisitely  fit  for  this  method  of  treatment.  Plastic 
operations  about  the  face  may  serve  as  a  fair  type. 

Bisinutli  and  Iodoform. — Certain  finely  powdered  substances,  as  iodo- 
form or  subnitrate  of  bismuth,  have  the  quality  of  rapidly  inspissating  blood 
and  serum  to  a  dry  crust.  Accordingly,  after  the  hgemorrhage  has  been 
controlled  and  the  wound  closed  by  suture,  a  quantity  of  the  substance 
chosen  is  dusted  over  the  sutures.  No  further  dressings  are  applied.  The 
escaping  bloody  serum  forms  a  paste  with  the  powder,  which  by  its  steriliz- 
ing property  prevents  decomposition,  while  the  paste  remains  moist.  Free 
access  of  air  will  hasten  exsiccation,  and  the  dry,  hard  crust  once  formed 
will  securely  prevent  further  ingress  of  dust  into  the  wound.  In  cases 
where  the  powder  is  washed  away  by  profuse  oozing,  the  dusting  has  to  be 
repeated  every  half-hour  after  the  operation,  until  the  object — the  forma- 
tion of  a  dry  crust — is  accomplished. 

XoTE. — Elderly  subjects  are  prone  to  iodoform  poisoning  if  the  agent  is  too  freely  used.  In 
these  cases  a  mixture  of  equal  parts  of  iodoform  and  bismuth  is  safer. 

Small  cuts,  abrasions,  and  burns  can  also  be  similarly  treated,  care  being 
taken  to  first  render  the  injuries  aseptic  by  ablution  with  corrosive  subli- 
mate lotion. 

XoTE. — Acetic  Acid. — An  excellent  way  of  treating  small  injuries  is  to  wash  them  as  soon  as 
possible — after  staunching  the  haemorrhage — with  pure  acetic  acid ;  or,  if  this  can  not  be  pro- 
cured, with  ordinary  vinegar.  The  intense  smarting  is  soon  controlled  by  the  application  of  cold 
water.  After  this  the  part  is  dried  with  a  towel.  The  dry  but  flexible  eschar  produced  by  the 
union  of  the  acid  with  the  exposed  tissues  gives  excellent  protection,  under  which  the  wound 
heals  without  reaction  or  suppuration.  The  great  advantage  of  this  form  of  treatment  will  be 
especially  appreciated  by  physicians,  as  the  eschar  is  insoluble,  and  the  injured  or  chapped  hands 
4 


12  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

treated  in  this  manner  can  be  washed  repeatedly  without  compromising  repair  or  risking  new 
infection  by  contact  with  pus. 

More  extensive  burns  or  denudations  are,  within  reasonable  limits,  also 
adapted  to  the  exsiccative  treatment.  However,  to  prevent  injury  of  the 
granulations  at  change  of  dressings,  due  to  their  matting  into  the  meshes 
of  the  gauze,  protecting  the  burned  surface  by  a  layer  of  rubber  tissue  will 
be  found  very  useful  and  commendable.  But  the  larger  the  absorbing  sur- 
face, the  more  caution  is  needed  in  the  use  of  iodoform. 

b.  Chemical  Sterilizatiox  combined  with  Exsiccatiox.  Dry 
Dressings. — In  extensive  injuries  or  large  operation  wounds  the  amount 
of  oozing  is  generally  so  large  that  dusting  alone  will  not  suffice  to  control 
decomposition.  Besides  the  patient's  person,  the  bedding  or  splints  will  be 
uncomfortably  soiled  ;  hence  it  is  necessary  to  provide  a  receptacle  for  the 
absorption  of  the  secretions.  For  this  purpose  absorbent  dressings  are  used 
that  have  been  rendered  aseptic  by  saturation  with  a  chemical  germicide  : 
iodoform,  corrosive  sublimate,  or  carbolic  acid.  A  small  surplus  of  the 
chemical  used  will  suffice  to  prevent  decomposition  of  the  absorbed  serum 
or  blood.  No  impervious  covering  (^lackintosh)  should  be  used  on  the 
outside  of  the  dressing,  as  the  free  admission  of  dustless  air  is  desirable. 
It  will  hasten  the  exsiccation  of  the  absorbed  secretions,  and  thus  insure 
the  protective  action  of  the  dressings,  even  if  the  chemical  employed  become 
evaporated  or  inert.  As  evaporation  of  the  deepest  parts  of  the  dressing — 
those  nearest  the  skin  and  farthest  from  the  surface — is  the  most  difficult, 
and  is  made  still  more  difficult  by  their  greater  saturation  with  serum,  a 
few  layers  of  iodoformized  gauze  placed  immediately  over  the  line  of  union 
will  be  of  very  great  service  in  hastening  exsiccation.  These  are  covered 
with  an  ample  mass  of  dressings  impregnated  with  corrosive  sublimate, 
which  are  held  down  with  a  roller  bandage. 

This  is  the  method  of  dressing  most  commonly  resorted  to  nowadays, 
and  has  been  found  the  most  simple  and  eifective  by  the  majority  of  modern 
surgeons. 

c.  Schede's  Modification  of  the  Dry  Dressing,  favoring  the 
Organization  of  the  Moist  Blood-Clot. — There  is  a  considerable  num- 
ber of  cases  where  extensive  loss  of  substance  consequent  upon  an  injury 
or  an  operation  precludes  approximation  of  the  walls  of  the  wound,  and 
renders  healing  by  primary  adhesion  impossible.  In  these  cases  a  blood- 
clot  forms  and  fills  up  the  defect  soon  after  the  injury  or  the  operation. 
In  an  aseptic  wound  this  blood-clot  serves  a  highly  useful  purpose  in  pro- 
tecting the  raw  surfaces,  preserving  their  vitality,  provided  that  the  integ- 
rity of  this  blood-clot  be  again  protected  from  exsiccation  on  one  and  from 
putrefaction  on  the  other  hand.  If  this  condition  is  fulfilled,  granulations 
will  gradually  consume,  as  it  were,  the  blood-clot ;  and,  by  the  time  the  clot 
disappears,  cicatrization  will  be  completed.  When  healing  under  the  moist 
blood-clot  is  aimed  at,  the  dressings  will  have  to  be  arranged  as  follows  : 
Immediately  over  the  wound  is  laid  a  suitably  trimmed  piece  of  fine  rubber 
tissue,  previously  well  soaked  in  carbolic  solution.     It  should  just  overlap 


ASEPTIC  WOUNDS— ASEPTIC  TREATMENT.  13 

the  edges  of  the  wound.  This  is  covered  with  a  layer  of  iodoformed  gauze, 
and  the  whole  is  well  enveloped  in  an  ample  covering  of  dry  corrosive  sub- 
limate gauze.  The  outer  dressings  will  absorb  and  render  innocuous  the 
surplus  of  blood  and  serum  ;  the  film  of  rubber  tissue  will  preserve  the 
underlying  clot  in  a  moist  condition. 

j^OTE. — Tissues  of  low  vascularity,  as  bone,  fasciae,  and  tendons,  will  certainly  undergo 
superficial  or  deep-going  necrosis  if  exposed  to  evaporation,  even  if  asepsis  be  rigidly  preserved. 

Case. — George  Braun,  German  Hospital,  aged  sixty-six.  Rodent  ulcer  of  the  nose.  Feb. 
19,  1886. — Extirpation  of  diseased  parts  followed  at  once  by  partial  rhinoplasty.  Sutured  parts 
dusted  with  iodoform.  Large  defect  on  forehead  (the  flap  including  periosteum)  inadvertently 
covered  with  iodoform  gauze,  without  interposition  of  rubber-tissue  protective.  When  the 
dressings  were  removed  ten  days  later,  no  suppuration  was  found,  but  the  surface  of  the  frontal 
bone  was  seen  to  be  exposed  (no  blood-clot),  and  very  dry.  After  four  weeks  the  first  sparse 
granulations  were  observed  sprouting  out  of  the  denuded  bone,  which  eventually  became  cica- 
trized over  in  the  fall  of  the  same  year.  Had  the  protective  not  been  omitted,  rapid  cicatriza- 
tion would  have  been  secured. 

d.  Simple  Chemical  Sterilizatiojst.  Moist  Dressiis^gs. — A  moder- 
ately moist  condition  of  the  outer  dressings  is  very  favorable  to  rapid  ab- 
sorption. This  fact  is  parallel  with  the  phenomenon  seen  if  a  thoroughly 
dry  sponge  is  thrown  on  water.  It  will  not  absorb  rapidly  and  sink,  but, 
on  the  contrary,  will  Jioat  on  the  surface  for  a  considerable  period  of  time. 
But  moisten  this  sponge  first  thoroughly,  then  squeeze  it  out  completely, 
and  then  throw  it  into  water,  and  it  will  at  once  become  filled  and  sink. 
Where  rapid  absorption  is  desirable,  as  in  the  presence  of  septic  or  fetid 
discharges,  and  where  clogging  of  the  drainage-holes  by  inspissated  secre- 
tions is  to  be  avoided,  dry  dressings  will  be  advantageously  replaced  by  a 
moist  dressing.  By  applying  a  piece  of  impermeable  material  to  the  out- 
side of  the  well-moistened  dressings,  evaporation  and  exsiccation  will  be 
prevented.  The  dressings  will  remain  in  a  moist  condition  for  an  indefi- 
nite period  of  time,  and  will  act  like  a  poultice. 

Ruhler  tissue  (not  rubber  sheeting)  is  an  excellent  and  cheap  substitute 
for  Lister's  ''Mackintosh"  and  his  ''protective."  It  can  be  had  in  all 
rubber  stores.  A  rather  stout  quality  is  the  best  article,  as  it  is  not  apt  to 
tear,  and  can  be  repeatedly  used  as  the  outer  covering  of  moist  dressings. 
It  ahoays  forms  the  outermost  layer  of  what  is  called  throughout  this  hook  a 
"moist  dressing.""  Oiled  silk,  well  soaked  in  carbolized  lotion,  is  a  toler- 
able substitute  for  rubber  tissue.  Another  substitute  is  waxed  paper,  or 
"  tracing  paper."  A  piece  of  stout,  brown  paper,  such  as  is  used  by  shop- 
keepers for  packing,  well  soaked  in  grease,  preferably  tallow,  will  answer 
on  a  pinch.  If  none  of  these  articles  can  be  had,  frequent  moistenings  of 
the  dressings  will  have  to  be  employed  in  order  to  prevent  evaporation. 
One  or  more  teaspoonfuls  of  carbolic  or  mercurial  lotion  instilled  into  the 
dressings  every  half-hour  or  so  will  have  the  desired  effect.  This  form  of 
moist  wound-treatment  was  very  extensively  employed  by  the  author  in  his 
seven-years'  service  at  the  German  Dispensary,  and  has  been  found  so  satis- 
factory both  to  patients  and  surgeons  that  it  is  still  the  standard  form  of 
moist  dressing  used  at  that  institution. 


14 


RULES  OF  ASEPTIC   AND  ANTISEPTIC  SURGERY. 


(2)  Preparation  of  DresxirKjs. 

a.  Gauze. — (iauze,  called  in  the  trade  cheese-cloth,  or  tobacco-cloth, 
forms  undoubtedly  the  most  convenient  material  for  wound-dressings.  It 
is  cheap,  can  be  bought  everywhere,  absorbs  well,  is  soft  and  pliable,  and 
can  be  easily  prepared  for  use  by  every  practitioner.     For  hospital  pur- 

14  in. 


!  UPPER     AND 

U  in.  \  LOWER    EXTREMITY. 
HIPJOINT. 
TRUNK. 


HERNIOTOMY. 
SCROTUM. 


SHOULDER  ^1     JOINT. 
AXILLA. 
ANKLE    l\    JOINT. 


14  m. 
24  in. 


NECK   AND   ARM 


n 


14  in. 


AXILLA 


AND    BREAST. 


28  in. 


EXSECTION  OF 


SHOULDER     JOINT. 


Win. 


AMPUTATION 


DP    THIGH. 


28  in.  28  in. 

Fig.  1. — Patterns  for  various  dressing.s,  modified  from  Neuber. 

poses,  moss  or  peat  dressings  in  the  shape  of  cushions  or  bags  are  more 
convenient.  In  the  practice  of  the  country  physician,  however,  they  are 
out  of  the  question. 


ASEPTIC  WOUNDS— ASEPTIC    TREATMENT. 


15 


{a)  Corrosive  Sublimate  Gauze. — The  raw  gauze  is  treated  as  follows  : 
To  free  it  of  its  oily  contents,  and  thus  to  make  it  more  absorbent, 
twenty-four  yards  of  the  fabric  are  boiled  for  an  hour  in  a  wash-kettle  filled 
with  sufficient  water  to  cover  the  material,  to  which  should  be  added  two 
pounds  of  washing-soda  or  a  pint  of  strong  lye.  After  this  the  stuff  is 
washed  out  in  cold  water,  passed  through  a  clothes- wringer,  and  immersed 
in  a  sufficient  quantity  of  a  1 :  1,000  solution  of  corrosive  sublimate  for 
twenty-four  hours,  then  passed  again  through  a  clothes-wringer,  dried,  and 
put  away  in  a  well-covered  glass  jar  until  required  for  use. 

The  fabric  is  so  folded  by  the  manufacturer  that  each  fold  is  just  one 
yard  long.  It  is  best  to  divide  the  twenty-four  yards  into  segments  of 
six  yards  each,  which  can  be  again  folded  by  the  surgeon  into  large  or  small, 
square,  oblong,  or  narrow  compresses  to  suit  each  individual  case.  If  a 
long  time  has  elapsed  since  the  preparation,  reimpregnation  with  a  1 :  1,000 
solution  of  corrosive  sublimate  is  advisable  before  use. 

Note. — la  a  stnall  proportion  of  cases,  contact  with  corrosive-sublimate  dressings  will  cause 
an  angry-looking  dermatitis,  which  at  the  first  blush  very  closely  resembles  erysipelas.     The 
absence  of  fever  and  sickness,  the  exact  limitation  of  the  rash  by  the  extent  of  the  dressings, 
will  soon  disperse  possible  doubts.     Profuse  application  of  vaseline 
or  some  other  bland  ointment  will  readily  dispose  of  the  irritation. 
The  strength  of  the  impregnation  should  be  then  also  reduced  by 
washing  the  gauze  in  water.     If  it  should  be  found  that  mercury  is 
not  borne  at  all,  it  should  be  substituted  by  carbolic-acid  solution  or 
Thiersch's  boro-salicylic  lotion,  or  creoline  emulsion. 

(5)  Iodoform  Gauze. — The  moist,  absorbent  gauze 
is  evenly  sprinkled  with  iodoform  powder  from  a 
pepper-box,  or  the  author's  iodoform,  duster,  well 
rubbed  into  the  meshes  by  hand,  and  then  put  away 
in  a  wide-mouthed  bottle. 

Boiler  hajidages  are  made  out  of  corrosive-sublimate 
gauze. 


Fig.  2 
iodoform 
screw  cap 


— The  author's 
duster,      with 
and  removable 
bottom  tor  replenishing. 


Note. — Roller  bandages  made  of  a  starched  fabric  known  as 
"  crinoline,"  or  "  crown-lining,"  are  very  useful  in  completing  every 
dressing.     They  are  moistened  in  water,  and  applied  over  the  dry 

roller-bandage.  They  soon  become  stiff  again,  and  make  a  very  compact  and  neat  dressing, 
that  will  not  shift  easily.  The  stuff  is  the  same  that  is  used  extensively  for  plaster-of-Paris 
bandages. 

In  emergencies  various  substances  of  absorbent  qualities  can  be  utilized 
as  dressings  ;  such  are,  for  instance,  cotton,  moss,  and  sawdust. 

i.  Absorbent  cotton",  or  common  cotton  batting,  well  soaked  in 
corrosive-sublimate  solution,  then  wrung  out,  will  make  a  tolerable  dress- 
ing. Its  drawbacks  are  that  it  packs  and  gets  hard  and  lumpy,  but,  prop- 
erly used,  it  will  answer  every  practical  purpose.  Care  should  be  taken 
not  to  tear  the  cotton  into  irregular  masses.  After  unrolling  it,  suitably 
large,  square  pieces  should  be  cut  off  with  the  scissors  ;  these  pieces  should 
be  folded,  then  soaked  in  the  lotion,  squeezed  out  hard,  and  unfolded  again. 


16  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

thus  preserving  their  shape  and  uniform  thickness.     Two  or  more  of  these 
pieces  laid  one  over  another  will  make  a  very  passable  dressing. 

Case. — Michael  B.,  aged  sixty-three,  sustained,  early  in  the  morning  of  November 
13,  1883,  a  compound  fracture  of  the  left  elbow-joint.  He  was  put  to  bed,  and,  under 
the  advice  of  the  family  attendant,  applications  of  cold  water  were  made  to  the  injured 
part.  Twelve  hours  after  the  injury,  the  author  found  a  Y-shaped  fracture  of  the  lower 
end  of  the  humerus,  the  conical  sharp  point  of  the  upper  fragment  protruding  through 
a  small  wound  above  the  olecranon.  The  joint  was  filled  with  a  large  clot,  and  some 
oozing  from  the  perforation  was  noticed.  The  edges  of  the  perforation  wound  were 
snugly  fitting  around  the  i)rotruding  bone,  and  during  the  subsequent  manipulations 
good  care  was  taken  not  to  allow  the  bone  to  slip  back.  Not  having  been  informed 
of  the  nature  of  the  injury,  the  author  arrived  unprepared  at  the  patient's  bedside.  The 
case,  however,  did  not  brook  delay,  hence  everything  had  to  be  extemporized.  Sev- 
eral ounces  of  a  ten-per-cent  alcoholic  solution  of  corrosive  sublimate  and  a  little  iodo- 
form were  ordered  from  the  nearest  druggist,  and  at  the  same  time  several  bundles  ot 
common  cotton  l)atting  were  procured.  Soon  plenty  of  a  1  :  1,000  corrosive-sublimate 
solution  was  ready,  in  which  square  pieces  of  cotton  were  soaked  as  described.  The 
patient's  poverty  compelled  an  economical  management  of  affairs.  An  old  but  clean 
bed-sheet  was  ripped  up  into  roller-bandages,  which  were  likewise  impregnated.  This 
done,  soap  and  hot  water  were  applied  to  the  elbow,  and  the  skin  was  shaved  clean  all 
around,  but  especially  near  the  perforation.  This  was  followed  by  a  vigorous  rubbing 
off  of  the  skin  and  protruding  bone  witli  the  mercuric  lotion,  which  at  the  same  time 
was  copiously  poured  over  the  region  of  the  elbow  from  a  pitcher.  After  this,  reduction 
of  the  protruding  bone  and  adjustment  of  the  fragments  by  extension  of  the  arm  was 
effected.  The  size  of  the  perforation-hole  at  once  became  much  smaller.  In  order  to 
provide  some  drainage,  a  small  fillet  of  cotton,  well  dusted  with  iodoform,  was  inserted 
into  the  cutaneous  part  of  the  outer  wound,  which  was  also  liberally  dusted.  Over 
this  were  placed  four  layers  of  cotton  pad?,  which  were  snugly  bandaged  to  the  limb. 
Two  lateral  splints,  made  of  a  pasteboard  box,  secured  the  extended  position,  in  which 
the  arm  was  suspended  from  a  nail  in  the  ceiling.  The  temperature  never  rose  al  ove 
100°  Fahr.  Nov.  19. — The  dressings  were  removed.  The  swelling,  due  to  the  etfusion 
of  blood,  had  disappeared  to  a  great  extent.  Oozing  had  ceased;  no  suppuration. 
The  fillet  of  cotton  was  withdrawn,  and  the  arm  was  put  up  in  a  plaster-of-Paris  splint 
flexed  at  a  right  angle.  Passive  motion  was  commenced  on  removal  of  the  splint,  four 
weeks  after  the  injury.  Ultimate  result  was  ascertained  in  October,  1884:  Flexion 
was  normal;  extension  could  not  be  carried  beyond  140°. 

c.  Sawdust. — With  a  view  to  the  occasional  impossibility  of  procuring 
any  of  the  common  dressing  materials  in  times  of  war  or  some  other  public 
calamity,  the  author  has  tested  the  efficacy  of  sawdust  as  a  dressing  during 
his  service  at  Mount  Sinai  Hospital,  extending  from  August  1,  1883,  till 
February  1,  1884.  Clean  pine,  spruce,  or  hemlock  sawdust  was  impreg- 
nated with  a  1  :  1,000  solution  of  corrosive  sublimate  for  twenty-four  hours  ; 
then  it  was  spread  on  sheets  of  muslin  to  dry,  and  finally  was  inclosed  in 
different-sized  bags  made  of  cheese-cloth  gauze.  To  prevent  the  shifting  of 
the  sawdust,  a  thin  layer  of  wood-shavings,  called  by  the  trade  "  excelsior," 
was  first  inserted  into  the  open  bag  ;  then  a  proportionate  quantity  of  saw- 
dust was  evenly  strewed  into  the  meshes  of  the  "excelsior,"  and  then  the 
bag  was  closed  by  stitches  made  with  threads  soaked  in  mercuric  lotion. 


ASEPTIC  WOUNDS— ASEPTIC  TEEATMENT.  17 

The  thickness  of  the  bags  varied,  according  to  their  size,  from  one  to  two 
inches.  After  the  wound  was  drained  and  sewed,  some  iodoform  gauze 
was  placed  next  to  it ;  then  came  one,  two,  or  more  smaller  bags,  and  on 
top  a  large  bag,  the  whole  being  snugly  fastened  with  roller  bandages. 

Aside  from  the  trouble  of  preparing  the  bags,  they  were  found  very  con- 
venient in  applying  and  quite  efScient  in  absorbing  blood  and  serum,  and 
preventing  decomposition. 

d.  Moss. — The  different  species  of  sphagnum,  coating  the  surface  of  peat- 
bogs and  the  trunks  of  dead  trees  in  our  northern  forests,  are  excellent 
material  for  making  dressing-bags.  On  account  of  its  cheapness,  small 
weight,  elasticity,  and  great  absorbing  power,  moss  has  displaced  other 
dressings  at  almost  all  of  the  surgical  clinics  of  Germany.  Its  preparation 
is  very  simple.  It  has  to  be  gathered  with  some  care — that  is,  with  no  ad- 
mixture of  the  soil.  After  being  dried,  it  is  impregnated  with  corrosive 
sublimate,  inclosed  in  gauze  bags,  and  is  ready  for  use.  Moss-bags  are  in 
daily  use  at  the  German  Hospital  since  1884,  and  can  not  be  praised  enough 
both  for  their  handiness  and  effectiveness.  But,  like  other  similar  dress- 
ings, they  are  not  adapted  to  the  needs  of  the  general  practitioner,  and  will 
find  their  princijDal  employment  in  hosjDital  practice. 


in.     PRACTICAL    APPLICATION    OF    RULES. 

1.  In  operating". — In  order  to  gain  a  coherent  idea  of  the  practical  work- 
ings of  the  aseptic  apparatus,  we  shall  now  rehearse  all  the  steps  of  a  well- 
conducted  operation. 

Assuming  that  a  cancerous  breast  is  to  be  removed  in  the  rooms  of  the 
patient,  it  is  first  necessary  to  select  a  suitable  person  to  act  as  nurse.  Her 
duty  is  to  administer  a  laxative  the  day  before  the  operation,  and  to  care- 
fully scrub  with  soap  and  brush  the  patient's  breast,  corresponding  shoulder, 
and  axillary  space  on  the  day  preceding  and  on  the  day  of  the  operation. 
A  clean,  well-lighted  room  is  selected,  out  of  which  all  unnecessary  furniture, 
hangings,  etc.,  should  be  removed.  A  bare,  well-scrubbed  floor  is  prefera- 
ble to  a  carpet.  One  or  two  narrow  kitchen-tables,  covered  with  a  quilt 
and  provided  with  a  straw  pillow,  will  make  a  capital  operating-table.  A 
piece  of  rubber  cloth  (3x4  feet)  is  placed  over  the  quilt,  and  a  clean  sheet 
is  laid  on  top.  The  nurse  provides  soap,  nail-brush,  plenty  of  hot  and  cold 
water,  and  towels.  The  operator  and  his  assistants  arrive  at  least  a  half- 
hour  before  the  appointed  time  of  the  operation.  Everybody's  hands  are 
washed  in  hot  water  with  soap  and  brush.  The  necessaries  are  now  un- 
packed and  arranged,  and  the  solutions  of  carbolic  acid  and  corrosive  sub- 
limate are  mixed,  for  which  purpose  six  or  eight  well-cleansed  quart  bottles 
should  be  held  in  readiness  by  the  nurse.  A  fountain  syringe  is  filled  with 
sublimate  solution,  and  suitably  suspended  from  a  nail  or  chandelier  near 
the  operating- table.  A  new  pail  or  bucket  is  filled  with  hot  water  for  rins- 
ing the  blood  out  of  the  sponges  ;  alongside  of  it  is  placed  a  basin  filled  with 


18  RULES  OF  ASEPTIC   AND  ANTISEPTIC   SURGERY. 

a  three-per-cent  solution  of  carbolic  acid  for  the  reception  of  the  cleaned 
sponges,  from  which  they  ought  to  be  handed  to  the  assistants  by  the  nurse. 
Two  more  japanned  tin  or  earthenware  basins  are  filled  with  a  corrosive- 
sublimate  solution,  and  placed  on  chairs  to  the  right  and  left  of  the  operating- 
table  for  the  occasional  rinsing  of  the  hands  of  the  operator  and  assistants. 
The  instruments  are  arranged  on  an  adjacent  table  in  a  certain  order,  which, 
to  prevent  confusion,  should  be  rigidly  adhered  to  during  the  entire  operation. 

Note. — The  author  has  found  that  it  is  very  convenient  to  be  independent  of  the  patient's 
resources,  as  far  as  the  necessary  vessels  for  sponges  and  instruments  are  concerned.  A  nest 
of  four  good-sized,  flat-bottomed  block-tin  wash-basins,  six  tin  soup-basins  (six  inches  diameter), 
and  four  tin  bake-pans,  will  serve  every  purpose,  and  the  small  expense  will  be  abundantly  re- 
paid by  the  cleanliness  and  sense  of  comfort  that  will  result.  Two  coats  of  some  reliable  oil-paint 
or  japan  will  prevent  corrosion  of  the  metal  vessels.  The  asphalt  is  dissolved  in  gasoline  or 
ether,  then  applied  evenly.     As  soon  as  the  solvent  evaporates,  the  pans  will  be  ready  for  use. 

All  vessels  are  wiped  clean.  The  knives,  sharp  and  blunt  retractors, 
scissors,  anatomical,  mouse-tooth,  and  dressing  forceps,  probes,  and  grooved 
director  should  be  put  into  one  pan  with  carbolic  lotion  ;  all  the  artery  for- 
ceps by  themselves  into  another  one.  Between  the  two  pans  is  placed  a 
third  one,  filled  with  hot  water,  in  which  all  the  instruments  not  in  actual 
use  should  be  rinsed  free  from  blood  before  being  returned  to  the  carbolic 
lotion.  This  will  keep  them  and  the  carbolic  lotion  clean  and  bright  all 
the  while,  and  no  time  will  be  lost  in  hunting  for  them  in  the  bottom  of  a 
turbid  pool  of  soiled  carbolic  solution.  In  a  smaller  tin  basin,  ligatures,  in 
another  one  needles,  are  arranged,  threaded  with  fine  (No.  0)  and  coarser 
(No.  1  or  2)  catgut.  A  third  small  basin  will  hold  the  drainage-tubes  and 
a  number  of  safety-pins. 

The  dressings  are  now  attended  to.  Eight  or  ten  small  (6x8  inches),  and 
just  as  many  large  (19x28  inches),  compresses  of  gauze  are  cut,  care  being 
taken  not  to  make  the  dressings  too  scanty,  as  an  ample  first  dressing  may 
save  the  trouble  of  many  subsequent  dressings.  The  best  rule  is  to  let  the 
outermost  compresses  overlap  the  wound  on  all  sides  by  at  least  eight  inches. 
To  this  should  be  added  a  sufficient  number  of  strips  of  iodoformed  gauze, 
three  or  four  rather  wide  gauze  roller-bandages,  and  the  same  number  of 
starched  or  crinoline  roller-bandages.  All  this  should  be  wrapped  in  a 
clean  towel  and  laid  aside  in  a  secure  place  until  needed. 

These  having  been  attended  to,  ansesthesia  may  commence  in  an  adja- 
cent room.  The  anaesthetizer  should  be  provided  with  ether  and  a  cone,  a 
tin  basin  for  the  reception  of  ejecta  in  case  of  vomiting,  a  towel,  a  hypo- 
dermic syringe,  a  wide-mouthed  bottle  with  morphine  solution  for  injections 
in  case  anaesthesia  be  imperfect,  a  similar  bottle  with  whisky  to  be  used  in 
case  of  heart-failure  ;  finally,  with  a  dressing-forceps  and  gag  for  withdraw- 
ing the  tongue  if  it  should  sink  back  on  the  epiglottis. 

The  anaesthetized  patient  is  placed  on  the  operating-table,  and  the  parts, 
being  exposed,  are  freely  soaped  and  shaved.  After  this  a  piece  of  rubber 
cloth  (3x4  feet)  is  so  placed  over  the  patient's  body  as  to  leave  exposed 
only  the  field  of  operation.     Now  the  parts  are  well  rubbed  off  with  a  towel 


ASEPTIC  WOUNDS— ASEPTIC  TREATMENT. 


19 


dipped  in  corrosive-sublimate  solution  and  freely  irrigated,  and  a  number 
of  clean  towels  wrung  out  of  the  same  solution  are  suitably  spread  around 
the  field  of  operation,  protecting  the  operator  and  assistants  against  contact 
with  the  clothing  or  body  of  the  patient,  and  providing  for  a  clean  place 
where  instruments  or  sponges  may  be  laid  down  for  a  moment  if  necessary. 
The  end  of  a  wet  towel  is  tucked  under  the  breast  and  armpit  of  the  side 
to  be  operated  on,  and  is  hung  over  the  edge  of  the  table  in  such  a  manner 
as  to  conduct  the  blood  and  irrigating  fluid  into  a  bucket  placed  on  the  floor 
underneath.  It  serves  as  a  drip-cloth.  Every  assistant  should  strictly  attend 
to  the  duty  allotted  to  him,  and  not  meddle.  All  unnecessary  talk  should 
cease,  and  the  work  proceed  in  an  orderly  manner.  The  first  assistant 
should  keep  his  eyes  open,  and  know  and  aid  the  operator's  intentions.  He 
should  be  alert,  but  not  over-zealous. 


Fig.  3. — Patient  made  ready  for  amputation  of  mamma. 

The  anaesthetizer  must  take  good  care  that,  in  case  of  vomiting,  no  ejecta 
are  thrown  on  the  wound  or  its  vicinity.  Towels  soiled  by  vomit  should 
be  at  once  replaced  by  clean  ones. 

Now  the  parts  are  distributed.  The  trustiest  man  serves  as  first  assist- 
ant over  against  the  operator  ;  a  younger  physician  at  the  left  of  the  operator 
is  second  assistant,  and  irrigates  or  helps  as  need  may  require ;  another 
physician  takes  charge  of  the  instruments  and  ligatures,  and  the  nurse 
attends  to  the  sponges,  and  keeps  in  readiness  "  sublimated  "  and  dry  towels 
and  a  pitcherful  of  corrosive-sublimate  solution. 

Aprons  are  donned,  everybody's  hands  are  finally  scrubbed  with  soap 
and  brush,  rinsed  in  mercuric  solution,  and  the  operation  begins, 
ft 


20  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

Note. — The  employment  of  copious  irrigation  during  operations  requires  measures  for  pro- 
tecting the  person  and  clothinj:  of  the  surgeon  against  the  influence  of  the  chemicals  commonly 
used.  An  ample  apron,  made  of  light  rubber  sheeting,  and  reaching  from  the  chin  to  the  toes, 
is  most  convenient,  and  can  be  easily  cleaned.  The  surgeon's  shoes  may  be  protected  by  a  pair 
of  light  rubbers.  However,  they  are  apt  to  sweat  the  feet.  The  author  overcame  this  draw- 
back by  the  use,  at  the  hospital,  of  wooden  pattens  (French  sabots)  worn  over  the  shoes.  They 
are  donned  and  doffed  without  the  aid  of  the  hands,  and  keep  the  feet  warm  and  dry,  and  can 
be  bought  at  75  Essex  Street,  New  York. 

In  removing  the  breast  and  contents  of  the  axilla,  lia?morrhage  should 
be  carefully  attended  to  by  ligaturing  every  bleeding  vessel  with  catgut. 
Having  removed  the  diseased  parts,  the  wound  is  carefully  irrigated,  each 
recess  being  attended  to  in  succession  ;  drainage  and  sutures  are  applied. 
The  projecting  end  of  the  drainage-tube  cut  off  "flush  "  is  transfixed  with 
a  safety-pin,  the  wound  is  once  more  irrigated  through  the  tube  so  as  to 
clear  it  of  clots,  and  the  clots  and  irrigating  fluid  are  removed  from  the 
wound  by  gentle  pressure  exerted  with  a  sponge  or  two.  lodoformed  gauze 
strips  are  next  placed  along  the  suture  and  around  the  drainage-tube,  pass- 
ing under  the  safety-pin,  and  a  few  pads  of  gauze  are  held  pressed  against 
the  wound  while  the  patient  is  slightly  raised  to  cleanse  her  back  and  face 
and  the  table  from  blood.  The  soiled  towels  are  replaced  by  dry  ones,  and 
the  dressing  completed  by  applying  as  many  gauze  compresses  as  required. 
These  are  fastened  rather  tightly  with  gauze  bandages,  the  other  breast  and 
arm-pits  being  first  padded  with  absorbent  cotton.  A  large,  square  piece  of 
absorbent  cotton,  somewhat  overlapping  the  dressings,  is  next  applied,  and 
snugly  held  down  by  crinoline  roller-bandages  ;  the  corresponding  arm  is 
included  by  the  bandage  or  is  placed  in  a  sling  ;  the  patient  is  brought  to 
bed,  and  an  opiate  is  administered. 

2.  Change  of  Dressings. — In  most  cases  where  the  rules  above  given 
are  conscientiously  and  intelligently  observed,  no  fever  will  follow  the 
operation.  After  the  effects  of  the  anesthesia  are  over,  the  patients  will 
be  found  cheerful  and  contented,  feeling  no  pain  or  sickness,  their  only  com- 
plaint being  the  tightness  of  the  bandage,  which  they  will  soon  learn  to 
bear.  The  temperature  will  range  during  the  first  three  days  at  about  100° 
Fahr. ;  after  that  it  will  sink  to  the  normal  standard.  Sometimes,  especially 
if  the  drainage  is  not  properly  placed,  and  some  serum  or  a  blood-clot  is 
retained  in  the  wound,  the  thermometer  will  indicate  from  100°  to  103° 
Fahr.  As  long,  however,  as  the  patient  is  cheerful,  and  does  not  feel  sick 
with  headache  and  general  dejection,  as  there  is  no  sharp,  throbbing  pain 
about  the  wound,  or  some  other  grave  disturbance  of  the  local  or  general 
comfort,  no  alarm  need  be  felt.  In  these  cases  we  have  to  deal  with  an  ele- 
vation of  temperature  benign  in  character,  and  identical  with  the  harmless 
fever  observed  after  almost  every  simple  fracture.  It  is  due  to  the  absorption 
of  the  extravasated  blood  or  lymph,  bland  and  harmless  on  account  of  the 
absence  of  putrefactive  changes.     This  is  Volkmann's  "aseptic  fever." 

The  temperature  soon  becomes  lowered,  appetite  reappears,  and  the  dress- 
ings need  not  be  disturbed. 


ASEPTIC  WOUNDS— ASEPTIC  TREATMENT. 


21 


Should,  on  the  other  hand,  the  patient  complain  of  chilliness,  headache, 
sickness,  general  dejection,  and  drawing  pains  in  the  limbs,  or  persistent 
and  increasing  pain  about  the  wound,  the  thermometer  indicating  at  the 
same  time  a  high  or  only  a  moderate  elevation,  the  dressings  should  at  once 
be  removed,  and  a  search  instituted  for  the  cause  of  the  disturbance. 

Previous  to  this  a  new  dressing  should  be  prepared  similar  to  the  one 
to  be  removed.  This  and  a  tin  pan  containing  carbolic  lotion,  with  a  dress- 
ing-forceps, anatomical  forceps,  scissors,  scalpel,  grooved  director,  and  a 
piece  of  drainage-tube,  together  with  another  vessel  holding  a  few  small 
pads  of  cotton  wrung  out  of  the  same  solution,  should  be  placed  on  a  small 
table  near  the  bed.  An  irrigator  filled  with  warm  carbolic  or  mercuric 
lotion  should  be  suspended  from  the  bedpost  or  a  nail,  and  a  pail  for  the 


iua's  after  amputatiou 


reception  of  the  soiled  dressings  should  be  at  hand.  A  piece  of  rubber  cloth 
covered  with  a  draw-sheet  and  spread  under  the  patient's  back  will  protect 
the  bed,  and  a  pus-basin  or  square  tin  pan  held  alongside  of  the  patient's 
thorax  will  receive  the  irrigating  fluid. 

After  this  the  turns  of  the  roller-bandage  are  cut  through  without  jar, 
and  the  outer  layers  of  the  dressing  are  gradually  removed.  As  the  deeper 
parts  are  being  raised,  irrigation  should  commence,  in  order  to  moisten  the 
gauze  and  aid  in  its  gentle  removal.  Care  should  be  taken  not  to  disturb 
the  drainage-tubes.  After  the  removal  of  the  soiled  dressings,  the  physi- 
cian's hands  should  he  carefully  cleansed  lefore  touching  any  part  of  the 
wound.  While  the  irrigating  stream  is  playing,  the  vicinity  of  the  wound 
is  gently  wiped  with  a  small  pad  of  moistened  cotton,  in  order  to  remove 
clots  of  blood  or  fibrin  that  can  not  be  dislodged  by  irrigation. 


22  RULES  OF   ASEPTIC  AND   ANTISEPTIC  SURGERY. 

If  the  edges  and  vicinity  of  the  wound  look  normal,  the  skin  pale,  not 
swollen,  and  not  painful  to  touch,  it  shoiild  be  forthwith  redressed.  A  care- 
ful physical  examination  of  the  internal  organs  will  then  certainly  reveal, 
as  the  cause  of  the  fever,  some  internal  complication,  as,  for  instance,  pneu- 
monia, or,  at  any  rate,  some  newly  developed  or  overlooked  disorder  inde- 
pendent of  the  wound. 

If  the  aseptic  measures  employed  were  insufficient,  the  edges  of  the 
wound  will  be  found  swollen,  reddened,  and  painful ;  the  wound  will  have 
lost  its  aseptic  character,  and  is  the  seat  of  a  septic  process  ending  in  sup- 
puration. Prompt  action  is  required  to  limit  the  inevitable  destruction  of 
tissue,  and  to  check  the  further  poisoning  of  the  system. 

From  this  moment  on,  aseptics  must  give  way  to  antiseptics  ;  prevention 
having  failed,  curative  measures  must  step  in  to  eliminate  the  mischief 
that  might  have  been  prevented  by  the  exhibition  of  more  care,  attention, 
or  skill. 

The  therapy  of  septically  infected  or  suppurating  wounds  will  be  treated 
in  the  following  chapter. 

In  case  that  the  course  of  the  healing  of  the  wound  is  correct,  as  indicated 
by  the  absence  of  local  or  general  disturbance,  the  first  dressing  may  remain 
unchanged  for  from  seven  to  forty  days.  Flesh-wounds  should  be  dressed 
on  the  fourth  to  the  seventh  day,  as  it  is  desirable  to  remove  the  drainage- 
tubes  and  sometimes  the  stitches.  The  finer  catgut  sutures  will  generally 
be  absorbed  by  this  time,  and  their  exposed  part  can  be  simply  wiped  away. 
Where  stout  retention  sutures  w^ere  employed  for  the  approach  of  the  edges 
of  a  wide,  gaping  wound,  they  will  be  found  cutting  through  the  tissues 
by  this  time,  and  quite  useless.  They  should  be  removed,  and  the  stitch- 
holes  dusted  with  iodoform.  According  to  the  completeness  of  the  result, 
the  dressings  will  have  to  be  changed  every  third,  fifth,  or  seventh  day, 
their  bulk  decreasing  with  the  diminution  of  the  secretions.  Finally,  the 
few  granulating  spots  need  only  a  dressing  consisting  of  a  patch  of  some 
unirritant  plaster,  such  as  empl.  cerussae  or  empl.  hydrarg.,  and  an  occasional 
touching  with  nitrate  of  silver,  to  aid  final  cicatrization.  Where  the  opera- 
tion has  involved  parts  of  the  skeleton,  as  in  amputations  of  extremities, 
exsections  of  joints,  necrotomies,  etc.,  the  dressings  have  to  be  left  undis- 
turbed much  longer.  After  exsections  of  the  knee-joint,  for  instance,  where 
bony  ankylosis  is  aimed  at,  the  first  dressing  is  not  removed  without  a  clear 
indication  before  the  thirtieth  or  fortieth  day.  No  patient  should  be  dis- 
charged ''cured"  before  cicatrization  is  complete,  as  it  has  happened  that 
such  "cured"  cases,  left  to  their  own  care,  contracted  erysipelas  the  day 
after  their  discharge,  and  died  of  it. 

Note. — All  the  manipulations  about  a  freshly  agglutinated  wound  should  be  very  deliber- 
ate and  gentle.  In  removing  stitches,  a  forceps  should  gently  raise  the  thread ;  then  it  should 
be  cut  as  close  to  the  stitch-hole  as  possible,  and  lightly  withdrawn.  Drainage-tubes  are 
grasped  at  the  projecting  end,  gently  rotated  to  and  fro  till  they  are  freely  movable,  then  with- 
drawn. Sometimes  it  will  be  found  that  a  painless  fluctuating  swelling  occupies  some  deeper 
part  of  the  wound.      In  these  cases  retention  of  serum  is  generally  caused  by  clogging  of  the 


ASEPTIC  WOUNDS— ASEPTIC  TREATMENT.  23 

drainage-tube  by  a  clot.  On  withdrawing  the  tube,  a  quantity  of  clear  or  turbid  yellowish  serum 
will  escape.  In  these  cases  it  is  good  to  replace  the  cleared  tubing  to  prevent  further  retention, 
and  thus  to  bring  about  contact  of  the  separated  walls  of  the  wound,  which  will  at  once  become 
adherent.     At  the  subsequent  change  of  dressings,  the  tube  can  be  definitively  removed. 

Case. — Mrs.  Clara  G.,  aged  forty-six.  Alveolar  glandular  cancer  of  an  aberrant 
(detached)  lohe  of  the  right  Ireast.  Tumor  of  the  size  of  a  small  fist,  situated  in  the 
axillary  space  close  to  the  edge  of  the  pectoralis  major  muscle.  It  was  connected  by 
a  stout  pedicle  with  the  adjacent  part  of  the  breast-gland  proper.  Jan.  16,  1885. — 
Amputation  of  mamma;  total  evacuation  of  axillary  fat  and  glands.  Drainage  by 
counter  opening  made  through  the  latissimus  dorsi  muscle.  Suture  of  the  entire  wound 
except  a  part  of  axilla,  where  the  skin  had  been  extensively  removed.  Course  of  heal- 
ing feverless.  Change  of  dressings  on  the  tenth  day.  Primary  union  of  all  the  sutured 
parts.  Axillary  wound  granulating.  Under  the  lower  flap  of  the  breast-wound  a  pain- 
less, soft,  fluctuating  swelling  discernible.  By  gently  inserting  a  probe  between  the 
corresponding  edges  of  the  united  wound,  entrance  into  this  sac  was  effected,  where- 
upon about  two  ounces  of  a  yellow,  slightly  turbid,  and  very  viscid  scum  escaped.  A 
small  drainage-tube  was  inserted,  and  the  wound  was  redressed.  Jan.  30th. — Walls 
of  the  cavity  were  found  firmly  adherent.     Tube  removed.     No  suppuration. 

The  iDterior  of  freshly  healed  wounds  of  normal  appearance  should  never 
be  syringed  ;  the  injection  of  a  strong  jet  of  fluid  is  unnecessary  and  often 
injurious;,  as  it  tends  to  separate  tender  adhesions. 

rv.     ASEPTIC    MEASURES    IN    EMERGENCIES. 

Unremitting  attention  to,  and  a  severe  self-discipline  in  always  carrying 
out  the  measures  of  strict  cleanliness  known  to  be  necessary  to  uniform 
success  in  the  management  of  wounds  will  gradually  become,  however 
irksome  in  the  beginning,  a  mere  matter  of  accustomed  routine.  As  the 
mind  and  senses  learn  to  exercise  vigilance  without  special  effort,  the  sur- 
geon's results  will  become  more  and  more  gratifying.  His  attention,  freed 
from  the  severe  strain  unavoidable  in  acquiring  command  of  the  detail  of 
a  difficult  business,  will  concentrate  itself  upon  higher  objects,  and  the 
smooth  routine  resulting  from  long  and  severe  training  will  not  divert 
attention  from  the  finer  detail  of  his  special  work. 

It  is  a  great  mistake,  paid  for  by  the  loss  of  limbs  and  lives,  to  believe 
that  the  mastery  of  practical  cleanliness  or  asepticism  can  be  acquired  with- 
out a  clear  comprehension  of  the  principle,  and  without  earnest  and  severe 
training  in  the  handicraft  of  asepticism.  The  wholesome  truth,  that  failure 
of  achieving  primary  union  in  fresh  wounds  is  mainly  and  almost  always 
due  to  one's  own  lack  of  knowledge  and  skill,  and  that  these  attributes  can 
be  secured  only  by  the  exercise  of  great  diligence  and  many,  often  unsuc- 
cessful trials,  should  be  constantly  present  in  our  mind.  Failures  are  bitter 
lessons,  but  their  honest  study  will  inevitably  bring  to  light  the  causative 
deficiencies,  and  will  teach  us  to  avoid  them. 

The  school  for  learning  to  employ  the  principles  of  asepticism  is  open 
to  every  general  practitioner  in  the  treatment  of  the  many  affections  and 
injuries  pertaining  to  minor  surgery.     Mistakes  made  in  the  removal  of  a 


24:  RULES  OF  ASEPTIC  AND   ANTISEPTIC  SURGERY. 

Aven  or  the  treatment  of  an  incised  wounrl  of  the  hand  are  easily  found  out 
and  easily  corrected.  They  carry  much  and  sometimes  more  instruction 
than  a  large  operation.  It  is  wicked  to  attempt  to  learn  the  first  lessons  of 
aseptic  surgery  in  capital  operations,  when,  possibly,  the  surgeon's  experi- 
ence is  bought  with  the  life  of  his  trusting  patient.  The  attempt  of  remoT- 
ing  an  ovarian  tumor,  for  instance,  should  be  permitted  only  to  those  who 
have  learned  to  invariably  heal  a  fresh  wound  by  primary  adhesion,  as  this 
is  the  first  and  sole  test  of  the  possession  of  the  ability  justifying  such  a 
grave  undertaking. 

Emergencies  will  necessarily  involve  varying  modifications  of  the  means, 
never  a  deviation  from  the  principle  of  asepticism. 

A  hasty  tracheotomy  for  the  removal  of  a  foreign  body,  a  herniotomy 
to  be  done  in  the  dead  of  night  amid  the  squalid  surroundings  of  a  tene- 
ment, or  the  first  care  of  a  compound  fracture  or  a  gunshot- wound,  will 
present  special  and  varying  diflSculties,  to  be  overcome  only  by  good  train- 
ing, circumspection,  and  versatility.  They  can  be  overcome,  as  many 
examples  in  the  experience  of  every  successful  surgeon  testify. 

In  addition  to  the  case  of  compound  fracture  of  the  elbow-joint  quoted  on 
page  16,  another  instructive  case  may  be  told  from  the  author's  experience. 

Case. — Herman  John,  laborer,  aged  sixty-one.  Right,  irreducible,  strangulated 
femoral  hernia.  Rupture  of  long  standing,  strangulated  since  the  evening  of  April  1, 
1882.  Symptoms  of  great  acuity  necessitated  prompt  action.  Dr.  H.  "Wettengel,  the 
family  attendant,  administered  the  anaesthetic  in  the  middle  of  the  afternoon  of  the 
following  day,  while  author  was  making  the  necessary  preparations  for  the  presuma- 
bly inevitable  operation.  The  place  was  a  narrow,  dark,  rear  room  of  a  rear  house  of 
a  squalid  tenement,  and  a  lamp  had  to  be  procured.  The  divested  patient's  pubic  and 
inguinal  region  was  shaved,  while  anaesthesia  progressed.  A  flat  bake-pan  was  covered 
with  one  of  the  few  clean  towels  to  be  had ;  on  this  were  spread  the  instruments,  and 
over  them  was  poured  a  quantity  of  a  five-per-cent  carbolic  lotion.  No  sponges  were 
on  hand,  as  the  summons  had  been  very  hasty,  and  no  time  was  aiforded  for  prepara- 
tions. Therefore,  a  part  of  a  clean  bed-sheet  was  torn  into  a  number  of  small  pads, 
which  were  well  soaked  in  the  same  lotion  to  serve  as  sponges.  A  remnant  of  the 
lotion  was  saved  in  a  pitcher  for  purposes  of  irrigation.  After  an  unsuccessful  attempt 
at  reposition,  the  inguinal  region  and  the  surgeon's  hands  were  once  more  well  soaped 
and  washed  off  with  the  carbolic  lotion.  The  epigastric  artery  had  to  be  tied,  and  ex- 
ternal herniotomy  was  performed.  A  small  knuckle  of  gut  slipped  back  easily  into  the 
abdominal  cavity,  but  evidently  did  not  represent  all  the  contents  of  the  sac,  within 
which  an  additional  soft  body  could  be  felt  that  resisted  every  gentle  effort  at  reposi- 
tion. The  sac  being  opened,  a  slender  portion  of  omentum  was  found  to  be  adherent 
to  it.  This,  being  dissected  away,  was  replaced  into  the  abdominal  cavity.  The  outer 
wound  was  well  irrigated,  and  united  by  a  number  of  catgut  sutures.  A  few  strands 
of  catgut  were  inserted  into  the  lower  angle  of  the  wound  for  drainage.  In  the  ab- 
sence of  other  dressings,  a  clean  sheet  was  used  for  the  manufacture  of  a  number  of 
compresses  and  roller-bandages.  These,  being  well  soaked  in  carbolic  lotion,  were 
applied  to  the  wound  in  the  shape  of  a  spica  bandage.  Vomiting  ceased.  Oozing 
being  very  scanty,  the  dressings  soon  became  dry,  and,  the  patient's  condition  being 
excellent  in  every  respect,  they  were  not  disturbed  until  a  fortnight  after  the  opera- 
tion, when  the  wound  was  found  healed  throughout  by  the  first  intention. 


ASEPTIC   WOUNDS— ASEPTIC    TREATMENT. 


25 


Yet  it  must  be  said  that  such  conditions  render  operating  very  risky, 
and  in  every  way  uncomfortable.  If  unavoidable,  the  additional  risk  must 
be  shouldered  by  the  patient  as  well  as  the  surgeon. 

Operating-  Bag  and  Kit.— 
Timely  preparation  made  in 
the  shape  of  procuring  a  well- 
arranged  hand-bag,  contain- 
ing the  most  necessary  arti- 
cles for  operating  in  an  emer- 
gency, will  well  repay  the 
small  expense  and  trouble. 

A  leather  hand-bag,  about 
sixteen  inches  long,  will  be 
sufficiently  large. 

Have  a  sufficiently  long, 
rather  stout  strap  sewed  to 
one  side  of  the  interior  of  the 
bag,  so  as  to  provide  loops  for  five  or  six  bottles,  which  will  be  held  safely 
in  the  upright  position.  The  first  loop  will  be  occupied  by  a  half-pound 
tin  can  of  ether  ;  the  second  is  allotted  to  a  two-ounce  bottle  of  corrosive- 
sublimate  solution  (ten  per  cent  alcoholic)  ;  the  third  to  a  four-ounce  bottle 
of  pure  carbolic  acid  ;  the  fourth  to  a  wide-mouthed  bottle  containing  cat- 
gut and  silk  of  different  sizes  on  spools  :  the  fifth  to  a  wide-mouthed  bot- 


FiG.  5. — Author's  operating  bag,  with  tin   pans   and 
rubber  cloths  strapped  to  it. 


Fig.  6. — Interior  of  operating 


tie  filled  with  drainage-tubes  of  different  sizes  in  carbolic  lotion  ;  the  sixth 
to  a  wide-mouthed  fruit-jar  with  tight  cap,  containing  two  or  three  dozen 
sponges  in  carbolic  lotion.     A  stout  pair  of  scissors  for  cutting  the  dress- 


20 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


ings,  a  dressing-forceps  for  the  anoestlietizer,  and  a  razor  can  be  conveniently 
stuck  in  behind  the  bottles.  On  the  other  side  of  the  bag  two  more  spaces 
are  reserved  for  a  dusting-box  filled  with  iodoform-powder  and  a  wide- 
mouthed  vial  for  an  assortment  of  surgeon's  needles.  The  bottles  contain- 
ing pure  carbolic-acid  and  corrosive-sublimate  solution  should  be  inclosed 


Fia.  7. — Gi^nuau  instrument-pouch. 


Fig.  8. — Interior  of  German  instrument-pouch. 


in  boxwood  or  tin  cases  for  safety.  A  side-flap  will  hold  nail-brush,  safety- 
pins,  and  one  complete  dressing  rolled  up  m  a  clean  towel.  The  body  of 
the  bag  is  reserved  for  the  instruments,  which  are  rolled  up  in  another  clean 
towel,  and  for  three  or  four  small  tin  basins,  together  with  a  fountain  syringe 
and  ether  cone,  each  kept  in  a  separate  rubber  sponge-bag. 

To  the  bottom  of  the  hand-bag  is  strapped  on  the  outside  a  nest  of  four 
oblong  tin  pans  of  fitting  size. 

Such  a  bag  contains  all  the  necessaries  for  an  emergency,  and  has  been 
used  by  the  author  many  years  with  much  satisfaction. 

Note. — Surr/ical  pocket-cases,  as  generally  sold  by  surgical  cutlers,  are  mostly  incomplete 
and  unsatisfactory.  Their  main  objection  is  the  small  size  and  frailty  of  the  instruments  con- 
tained in  them.  The  instrument-pouch  depicted  in  Figs.  7  and  8  is  very  complete,  and  is  worn 
strapped  to  the  waist  underneath  the  coat.  It  contains,  besides  the  instruments  held  by  a  com- 
plete pocket-case,  a  sharp  spoon,  a  key-hole  saw,  a  flat  oblong  iodoform  dusting-box  of  hard 
rubber,  and  a  set  of  diverse  detachable  knife-blades,  that  can  be  fitted  to  smooth  hard-rubber 
handles,  all  very  easy  to  clean.  In  an  emergency,  the  hip-pouch  will  be  found  large  enough  for 
the  reception  of  one  complete  dressing  to  a  moderate-sized  wound. 


SOILED   WOUNDS— ANTISEPTIC  TREATMENT.  27 


CHAPTEK   III. 

SOILED  WOUNDS.— ANTISEPTIC  TREATMENT— DIFFERENCE  BETWEEN 
ASEPTIC  AND  ANTISEPTIC  METHODS.— ILLUSTRATION  OF  ANTI- 
SEPTIC METHOD. 

Ix  the  preceding  chapter  the  treatment  of  freshly  made,  clean,  or  un- 
contaminated  wounds  was  discussed  ;  its  subject  was  the  aseptic  form  of 
treatment — that  is,  the  manner  in  which  a  fresh  or  clean  wound  has  to  be 
managed  in  order  to  prevent  its  septic  infection. 

The  aseptic  discipline  is  a  purely  preventive  one. 

Antiseptic  treatment,  on  the  other  hand,  refers  to  such  wonnds  as  have 
become  the  seat  of  infection,  causing  inflammation,  suppuration,  or  the 
higher  forms  of  sepsis — phlegmon  and  gangrene.  The  object  of  the  anti- 
septic treatment  is  the  limiting  and  elimination  of  estahlislied  septic  pro- 
cesses by  drainage  and  disinfection.  It  is  also  preventive,  but  in  a  narrower 
sense  than  the  aseptic  method.  There  all  mischief  is  prevented  from  the 
outset ;  here  further  extension  of  present  mischief  is  sought  to  be  checked. 
The  aseptic  method  will  generally  preserve  all  the  parts  involved  ;  the  anti- 
septic method  can  not  restore  the  integrity  of  parts  destroyed  by  ulceration, 
suppuration,  or  gangrene. 

Illustration  of  Antiseptic  Metliod.—^ov  the  sake  of  illustration,  let  us 
go  back  now  to  our  former  example  of  breast-amputation. 

Some  gross  fault  having  been  committed,  such  as,  for  instance,  the  use 
of  unclean  instruments,  or  a  sponge  that,  having  fallen  to  the  floor,  was 
picked  up  by  the  nurse  and  was  handed  for  use  in  the  wound.  The  mild 
course  of  the  case  is  compromised,  and  trouble  will  follow. 

In  such  cases  the  patient's  general  condition  is  deeply  disturbed,  more 
or  less  high  fever  is  present,  with  headache,  sickness,  general  dejection,  and 
drawing  pains  in  the  limbs.  The  tongue  is  foul,  much  thirst  and  loss  of 
appetite  are  complained  of.  The  wound  is  painful  and  throbbing,  and  the 
patient  dreads  any  movement  lest  the  sore  parts  be  hurt. 

Under  these  circumstances  an  immediate  examination  of  the  wound  is 
imperative.  The  preparation  mentioned  in  the  preceding  chapter  being 
made,  the  wound  is  exposed.  Its  edges  and  the  vicinity  will  be  found  angry- 
looking,  swollen,  hot,  and  tender. 

The  stitches  should  be  all  removed.  The  point  of  the  grooved  director 
should  be  inserted  between  the  edges  of  the  wound,  which  are  gradually 
separated  till  the  index-finger  can  be  insinuated.  Exerting  gentle  pressure, 
the  wound  is  thus  opened  throughout  its  entire  extent.  One  or  more  small 
foci  containing  pus  will  be  laid  open  and  discharged.  The  wound  should 
be  carefully  irrigated  with  warm  mercuric  lotion  till  the  slight  haemorrhage 
ceases,  and  lightly  filled  with  sublimated  gauze.  After  this  the  outer  dress- 
ings, with  the  addition  of  an  externally  placed  piece  of  rubber  tissue  to  pre- 


28  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGEEY. 

vent  evaporation,  should  be  renewed,  and  the  timely  interference  will  be 
soon  rewarded  by  a  decided  improvement  in  the  patient's  condition.  In 
these  cases  the  dressings  must  be  changed  as  often  as  they  become  soiled 
through.  If  the  fever  should  continue,  renewed  search  must  be  instituted 
for  overlooked  points  of  retention. 

In  some  cases  examination  of  the  wound  will  reveal  only  partial  or  quite 
circumscribed  inflammation.  In  locating  the  exact  point  of  retention,  the 
sensations  of  an  intelligent  patient  will  greatly  aid  the  surgeon.  If  the 
retention  be  near  the  edges  of  tiie  wound,  the  grooved  director  will  easily 
separate  them  and  find  its  way  into  the  focus.  A  dressing-forceps  should 
be  then  insinuated  along  the  director,  and  withdrawn  with  its  branches 
partly  opened.  Pus  escaping,  a  slender  drainage-tube  should  be  inserted 
into  the  track. 

If  the  point  of  retention  be  remote  from  the  edges  of  the  wound, 
and  its  locality  well  marked  by  redness  and  pain,  an  incision  will  best 
answer  the  purpose,  and  often  may  prevent  suppuration  of  the  rest  of 
the  wound. 

Let  us  assume  that  for  one  reason  or  another  nothing  efficient  was  done 
to  relieve  the  patient  on  the  second  or  third  day  after  the  operation.  Finally, 
the  increasing  severity  of  the  symptoms  will  compel  some  action,  and,  the 
wound  being  laid  bare,  the  following  state  will  be  generally  met  with  :  The 
wound  will  be  more  or  less  gaping,  ichor  or  pus  escaping  everywhere  ;  the 
skin  will  appear  flushed,  swollen,  and  painful ;  the  edges  of  the  wound  will  be 
marked  by  a  grayish-yellow,  closely  adherent  coating,  that  extends  through 
its  whole  interior.  This  coating  represents  molecular,  often  deep-going 
necrosis  of  the  wound  surface.  Independent  abscesses  will  often  be  found 
established  along  the  connective-tissue  planes  contiguous  with  the  wound, 
and  should  be  forthwith  incised  and  drained.  The  wound  should  be  well 
irrigated  and  loosely  filled  with  sublimated  gauze.  Over  this  should  be 
applied  a  moist  dressing  of  ample  proportions,  covered  with  an  overlapping 
piece  of  rubber  tissue  to  prevent  evaporation  and  inspissation.  The  secre- 
tions will  thus  be  readily  and  continuously  drained  away  and  disinfected, 
and  the  warm  moisture  of  the  dressings  will  at  the  same  time  exert  a  very 
soothing  influence  upon  the  inflamed  parts.  Frequent,  at  least  daily,  change 
of  dressings  is  proper,  accompanied  by  copious  irrigation.  Detached  shreds 
of  necrosed  tissue  should  be  removed  with  thumb-forceps  and  scissors.  If 
new  abscesses  form,  they  must  be  found  and  opened  jiromptly.  The  fever 
will  soon  abate,  and  the  wound  will  gradually  assume  a  clean  granulating 
appearance.  As  the  amount  of  secretion  diminishes,  the  dressings  should 
be  changed  less  frequently. 

Essentially,  the  so-called  '•  idiopathic  "  plilecjmon,  or  spontaneous  sup- 
puratio7i  (abscess)  is  a  form  of  local  septic  infection  which  can  be  traced 
back  to  an  infection  extending  from  a  lesion  of  the  skin  or  the  mucous 
membranes. 

Even  the  suppurative  or  infectious  form  of  osteomyelitis  must  be  classed 
under  this  heading. 


THE  TREATMENT  OF  ACCIDENTAL  WOUNDS.  29 

But,  on  account  of  the  great  practical  importance  of  the  subject,  requir- 
ing special  consideration  of  several  anatomical  regions  involving  important 
modifications  of  the  antiseptic  procedure,  it  is  deemed  expedient  to  treat 
of  this  theme  in  a  special  chapter  (page  183). 


CHAPTEK   IV. 


SPECIAL   RULES  REGARDING    THE   TREATMENT  OF  ACCIDENTAL 

WOUNDS. 

I.     TEMPORARY    MEASURES. 

Taking  charge  of  a  fresh  case  of  accidental  wounding,  the  surgeon 
should  bear  in  mind  that,  on  the  one  hand,  by  the  avoidance  of  suppura- 
tion, a  complete  or  almost  complete  restitution  of  normal  conditions  can  be 
accomplished  in  a  great  majority  of  cases  ;  on  the  other  hand,  suppuration 
will  enormously  increase  the  gravity  of  a  given  injury.  A  compound  fract- 
ure of  the  leg,  or  an  incised  wound  of  the  wrist,  with  opening  of  joints  and 
severing  of  arteries,  veins,  and  tendons,  may  serve  as  examples. 

In  approaching  a  fresh  case  of  bloody  injury,  we  should  always  consider 
the  possibility  that  the  wound  may  be  surgically  clean,  or  may  still  be  asep- 
tic, and  that  our  first  ministrations  should  not  carry  septic  contamination 
into  the  wound,  and  thus  harm  the  patient  instead  of  aiding  him.  As  a 
matter  of  fact,  a  large  proportion  of  incised  and  lacerated  wounds,  of  com- 
pound fractures  by  blunt  force  or  gunshot,  are  aseptic.  They  need  no  dis- 
infection. The  surgeon's  first  object  should  be  in  these  cases  not  to  spoil 
matters  by  liastij  action  and  ill-considered  zeal.  With  the  comparatively 
rare  exception  of  injuries  to  large  vessels  accompanied  by  dangerous  haem- 
orrhage, where  immediate  action  is  unavoidable,  conditions  should  be  created 
by  the  surgeon,  under  which  safe — that  is,  aseptic— approach  to  the  wound 
is  made  possible.  Temporary  protection  of  the  wound  in  the  shape  of  a 
simple  dressing  is  meant  thereby.  lodoform-powder  dusted  profusely  over 
the  wound  and  its  vicinity,  a  compress  made  of  a  clean  towel  dipped  in  hot 
water  or  carbolic  lotion,  also  well  dusted  with  iodoform  and  tied  on  to  the 
wound,  will  be  sufficient.  The  addition  of  a  temporary  splint  in  cases  of 
compound  or  gunshot  fracture  will  make  transportation  to  the  patient's 
home  or  to  a  hospital  possible,  and  will  thus  afford  time  for  the  absolutely 
necessary  preparations.  Extensive  or  even  superficial  examination  of  an 
accidental  wound  by  probing  or  digital  exploration  in  the  street,  on  a  train, 
or  in  a  railroad-station  or  drug-shop,  is  strongly  to  be  condemned,  as  it 
almost  necessarily  exposes  the  wound  to  unavoidable  infection.  Meddle- 
some and  untimely  surgery  of  this  kind  smacks  of  ostentation,  is  unneces- 
sary, and  in  many  cases  positively  more  dangerous  than  the  injury  itself. 


30 


RULES   OF   ASEPTIC   AND   ANTISEPTIC   SURGERY. 


Bergmann's  experience  during  tlic  Russo-Turkish  war  has  shown  that  most 
gunshot  wounds  are  aseptic,  and.  tliat,  witli  the  exception  of  those  cases 
where  shreds  of  soiled  clotliing  or  gun-wads  were  carried  along  by  the  pro- 
jectile into  the  bottom  of  the  wound,  healing  without  suppuration  can  be 
confidently  exj^ected  if  the  wound  is  not  infected  by  meddlesome  and  un- 
cleanly surgery.  These  experiences  refer  principally  to  gunshot  fractures 
of  the  knee-joint. 

As  a  matter  of  fact,  it  may  be  safely  assumed  that  an  examination  by 
l^robing  or  digital  exploration,  i>erformed  on  the  filthy  floor  of  a  public 
l)lace  or  on  the  street  pavement,  even  by  the  most  experienced  surgeon,  can 
not  be,  and  is  not  cleanly  or  aseptic.  It  is  extremely  dangerous,  unnecessary, 
hence  culpable.  Even  in  most  cases  of  profuse  arterial  hsemorrliage,  mesial 
constriction  with  an  extemporized  tourniquet,  as,  for  instance,  the  "  Span- 
ish windlass,"  or  digital  compression  of  the  afferent  arterial  trunk,  can  be 

successfully  employed,  while  the  patient 
is  transferred  into  a  suitable  locality, 
where  permanent  relief  can  be  safely  af- 
forded by  deligation. 

The  collected  and  businesslike  manner 
of  the  surgeon  will  at  once  allay  confu- 
sion, prevent  hasty  and  injurious  interfer- 
ence, will  infuse  the  patient  and  those 
present  with  hope  and  confidence,  and 
will  facilitate  well- 


FiG.  9. — Extemporized  tourniquet — "  Spauisli  winclluss." 


considered  and  ra- 
tional action. 

As  a  rule,  the 
fate  of  a  fresh 
wound  is  deter- 
mined by  the  views 
and  training  of  the 
physician  who  first 
attends  to  it.  If 
the  patient  be   so 

fortunate  as  to  fall  in  with  a  man  fully  imbued  with  the  spirit,  and  familiar 
with  the  practice  of  aseptic  surgery,  he  is  truly  to  be  congratulated,  because 
his  chances  of  avoiding  suppuration  are  excellent.  If  his  first  attendant  be 
one  of  those  to  whom  wound  infection  by  dust  or  filth  adherent  to  hands 
or  a  probe  be  a  myth,  he  is  to  be  pitied.  Without  previous  cleansing,  im- 
mediate probing  of  the  gunshot  wound  of  a  vertebra,  for  instance,  accom- 
panied by  digital  exploration,  will  be  performed  on  the  patient  extended  on 
a  mattress  laid  on  the  dirty  floor  of  a  railroad  station. 

Of  course,  the  bullet  will  not  be  found,  and  nothing  beyond  the  infec- 
tion of  the  wound  will  be  accomplished.  A  dressing  will  be  applied  any- 
way, and  the  patient  will  be  taken  home.  Suppuration,  that  otherwise 
might  have  been  avoided,  will  surely  set  in,  and  the  patient  is  doomed.     No 


THE   TREATMENT   OF   ACCIDENTAL  WOUNDS.  31 

amount  of  consulting  can  devise  a  way,  for  no  surgical  skill  can  establish 
efficient  drainage  of  the  inaccessible  parts  of  the  wound.  The  chances  for 
recovery  were  thrown  away  here  from  the  outset. 

On  taking  charge  of  a  fresh  wound,  the  fearful  and  often  irremediable 
consequences  of  a  first  false  step  should  be  always  present  to  the  mind  of 
the  surgeon,  and  his  attention  should  be  directed  chiefly  to  the  avoidance  of 
septic  infection.  A  temj)orary  aseptic  dressing  having  been  applied,  the 
general  condition  and  comfort  of  the  patient  should  be  looked  to  by  the 
administration  of  stimulants  or  sedatives.  After  transfer  home  or  to  a 
hospital,  the  necessary  measures  for  permanent  relief  should  be  carried  out 
as  soon  as  the  patient's  general  condition  will  permit. 

II.    DEFINITIVE    RELIEF. 

Preparations,  comprehensive  and  thorough,  as  required  for  an  aseptic 
operation,  should  now  be  made  in  the  manner  described  in  Chapter  II. 

The  patient  is  well  stimulated  if  necessary,  is  anaesthetized  if  the  case 
require  it,  and,  his  clothing  being  removed  by  cutting  or  in  some  other 
proper  manner,  he  is  placed  on  the  ojDerating  table. 

After  this  should  come  a  careful  cleansing  and  sterilization  of  the  sur- 
geon's and  his  assistant's  hands  by  scrubbing  with  soap  and  brush  and 
immersion  in  a  germicide  lotion,  followed  by  a  likewise  thorough  cleansing 
of  the  integument  in  the  vicinity  of  the  wound.  Plenty  of  soap-lather, 
with  the  use  of  a  razor,  scrubbing  with  soap  and  brush,  rubbing  and  wash- 
ing off  with  a  solution  of  corrosive  sublimate,  will  soon  accomplish  this. 

1.  Contaminated  Wounds. — The  character  of  further  procedures  will  have 
to  be  decided  by  the  answer  to  the  question  :  Is  the  wound  clean  or  is  it  con- 
taminated? Gross  evidence  of  contamination,  such  as,  for  instance,  street- 
dirt  imbedded  in  the  wound  or  the  clots,  or  the  knowledge  that  the  wound- 
ing was  done  with  a  filthy  instrument,  as,  for  instance,  a  foul  and  fetid 
butcher's  cleaver,  will  answer  the  question  in  the  affirmative.  In  these 
cases  the  leading  object  should  be  thorough  cleansing  and  disinfection 
of  the  wound,  followed  by  very  comprehensive  measures  at  drainage.  If 
the  external  wound  be  small,  it  has  to  be  well  enlarged,  so  as  to  afford  a 
good  insight.  Every  nook  and  recess  of  the  wound  should  be  systematically 
gone  through,  cleansed  of  clots  and  dirt,  thoroughly  irrigated,  and  well 
drained.  G-reat  care  must  be  taken  not  to  overlook  recesses,  as  one  particle 
of  filth  left  behind  unawares,  may  cause  very  grave  trouble. 

Drainage  of  the  more  remote  recesses  should  be  made  as  direct  as  possi- 
ble ;  that  is,  a  rubber  tube  carried  to  the  surface  from  a  distant  corner  of 
the  wound  through  a  properly  placed  counter-incision,  will  be  more  direct, 
therefore  better,  than  a  long  tube  bent  or  twisted  and  brought  out  through 
a  distant  opening. 

Haemorrhage  must  also  be,  of  course,  well  stanched  by  ligature  or 
otherwise. 

Divided  tendons,  nerves,  muscles,  or  fractured  bones  are  next  united  by 


32  RULES  OF   ASEPTIC  AND  ANTISEPTIC  SURGEEY. 

suture,  and,  if  the  edges  of  the  wound  be  viable,  they  are  also  approximated 
by  sutures.  Where  extensive  loss  of  substance  precludes  uniting  of  the 
edges,  or  where  uncontrollable  oozing  prevails,  the  wound  should  be  packed. 
This  is  best  done  by  first  lining  the  entire  wound  with  one  layer  of  iodo- 
formized  gauze,  within  which  are  packed  a  suitable  number  of  loose  balls  of 
sublimated  gauze.  After  a  final  irrigation  and  clearing  of  the  drainage- 
tubes,  the  wound  and  its  vicinity  are  enveloped  in  a  moist  dressing  that 
should  be  protected  from  evaporation  by  a  large  piece  of  rubber  tissue  or 
Mackintosh.  In  case  of  fracture,  the  limb  is  supported  by  a  splint.  On 
account  of  their  frequency,  and  their  gravity  in  case  of  suppuration,  inju- 
ries to  the  cranium  and  their  treatment  may  receive  special  mention. 

Scalp-wounds  have  been  held  undeservedly  in  bad  repute  on  account  of 
their  alleged  tendency  to  suppurate.  They  heal  as  kindly  as,  and  in  fact, 
on  account  of  their  great  vascular  supply,  heal  better  than,  many  other 
wounds,  provided  that  they  be  first  carefully  cleansed,  well  drained  before 
suturing,  and  sufficiently  protected  by  a  suitable  dressing  from  subsequent 
contamination. 

In  case  of  a  greater  denudation  of  the  cranium,  the  loose  scalp  should 
be  raised  (after  shaving  and  thorough  cleansing  of  the  skin),  blood-clots 
should  be  turned  out,  and  the  wound  well  irrigated  and  rubbed  out  with 
corrosive-sublimate  lotion.  A  bistoury  is  inserted  into  the  deepest  part  of 
the  recess  formed  by  the  flap,  and  thrust  out  through  it.  Into  this  opening 
a  short  piece  of  slender  tubing  is  placed,  after  which  the  edges  of  the 
wound  are  brought  together  by  an  exact  line  of  sutures.  A  dry  dressing 
will  be  proper  in  these  cases. 

If  a  compound  fracture  of  the  cranium  be  present,  the  first  care  of  the 
surgeon  should  be  to  ascertain  that  no  septic  material  remain  imbedded  in 
the  recesses  of  the  wound.  The  external  wound  must  be  adequately  en- 
larged to  permit  of  thorough  inspection,  cleansing,  and  disinfection.  After 
this  the  nature  of  the  fracture  should  receive  due  attention.  Often  foreign 
matter,  such  as  street  dirt  or  the  hair,  will  be  found  impacted  between  the 
depressed  fragments.  In  this  case  the  edges  of  the  fractured  area  are  to  be 
sufficiently  removed  by  the  aid  of  the  chisel  and  mallet  to  permit  of  an 
easy  elevation  or  extraction  of  the  fragments  and  foreign  matter.  This  is 
followed  by  a  thorough  cleansing  of  the  exposed  dura  mater,  especially  of 
the  recesses  formed  by  the  stripping  off  of  this  membrane  from  the  inter- 
nal surface  of  the  skull.  If  the  foreign  body  or  fragments  of  bone  have 
injured  the  dura  mater,  the  rent  must  be  widened,  in  order  to  permit  of 
careful  extraction  and  cleansing.  A  slender  drainage-tube  having  been  in- 
serted in  the  dural  rent,  its  edges  are  approximated  by  a  few  catgut  stitches. 
The  chips  or  button  of  bone,  removed  eitlier  by  the  chisel  and  mallet  or 
by  the  trephine,  should  be  saved  and  preserved  in  a  boro-salicylic  solution 
till  the  operation  be  completed,  when  they  are  replaced  in  the  cranial  de- 
fect, over  which  the  skin  is  united  by  an  external  suture,  leaving  sufficient 
space  for  the  emergence  of  the  drainage-tube.  A  moist  dressing  is  appro- 
priate in  these  cases. 


THE  TKEATMENT  OF  ACCIDENTAL  WOUNDS.  33 

Case. — Eegino  Libertello,  aged  thirty,  an  Italian  cobbler,  was  admitted  to  Mount 
Sinai  Hospital,  on  November  30,  1889,  with  a  fresh  scalp-wound,  two  inches  long,  over 
the  left  half  of  the  occipital  bone,  and  parallel  to  the  sagittal  suture.  On  exposure  of 
the  bottom  of  the  wound  a  deeply  depressed  fracture  was  noticed,  and  within  one  of  the 
fissures  a  small  bundle  of  the  patient's  hair  was  found  to  be  imprisoned,  where  it  had 
been  evidently  driven  by  the  brickbat  that  had  caused  the  fracture.  The  general  con- 
dition was  good,  no  cerebral  symptoms  of  any  gravity  being  present,  with  the  excep- 
tion of  a  marked  dilatation  of  the  right  pupil.  The  presence  of  hair  within  the  cleft 
of  the  fracture  was  considered  an  ample  indication  for  thorough  disiufection ;  hence  the 
man  being  anesthetized,  the  scalp  shaved  and  disinfected,  the  wound  was  well  en- 
larged, and  the  periosteum  raised  from  the  skull.  The  edges  of  the  oblong  depression 
were  carefully  removed  by  the  chisel  and  mallet,  the  loose  fragments  of  the  outer  and 
inner  table  extracted,  when  the  uninjured  dura  mater  carue  in  view.  A  portion  of 
the  fractured  inner  table  was  left  in  situ,  and,  after  thorough  wiping  and  irrigation, 
a  fillet  of  iodoform  gauze  was  applied  to  the  dura,  and  carried  out  of  the  wound  by 
its  lower  angle.  A  number  of  external  catgut  stitches  and  a  moist  dressing  com- 
pleted the  procedure.  The  depressed  area  was  ovoid,  measuring  one  by  three  quar- 
ters of  an  inch.  Immediately  after  the  operation  the  pupils  were  equal  in  size.  The 
drainage  was  removed  on  December  4th.  The  patient  was  discharged  cured  on 
December  14th. 

If  the  steps  described  above  are  adequately  taken,  as  a  rule  no  septic 
fever  and  no  destructive  suppuration  will  follow  an  accidental  injury  ; 
though  aseptic  fever,  due  to  absorption  of  non-decomposed  secretions,  may 
often  enough  be  observed. 

Tissues  or  bone  whose  vitality  was  compromised  by  the  crushing  force 
causing  the  injury  will  be  gradually  detached.  This  will  be  accompa- 
nied by  a  rather  scanty  secretion  of  thinnish  sero-pus,  and  very  little 
fever,  if  any. 

Case. — P.  S.,  agent,  aged  forty-six,  was,  January  26,  1886,  while  in  a  state  of  deep 
alcoholic  intoxicatii:)n,  run  over  by  a  heavily  laden  truck,  and  was  at  once  brought 
to  the  German  Hospital,  where  he  was  anaesthetized  about  two  hours  after  the  acci- 
dent. There  was  hardly  any  shock  noticeable.  The  soiled  and  torn  garments  were 
cut  away  from  the  extremity,  which  was  then  carefully  cleansed  from  adherent 
street-dirt  and  blood-clot  by  the  application  of  soap,  hot  water,  the  scrubbing- 
brush,  and  a  razor.  There  was  very  little  external  hemorrhage  present,  but  the  ap- 
pearance of  the  member  gave  unmistakable  evidence  of  extensive  and  serious  in- 
jury. A  laceration  of  the  integument  in  front  of  and  corresponding  to  the  middle  of 
the  left  leg,  four  inches  long,  was  found.  Also  compound  comminuted  fracture  of  the 
tibia  and  fibula.  The  tibia  was  broken  into  four,  the  fibula  into  at  least  three  frag- 
ments. Severe  haemorrhage  from  the  torn  tibialis  antica  artery  had  caused  an  enor- 
mous infiltration  of  the  leg,  which  had  attained  double  the  size  of  its  fellow,  and 
was  quite  cold.  The  integument  was  much  discolored  in  the  vicinity  of  the  exter- 
nal wound,  and  very  tense.  Elsewhere  the  skin  appeared  abnormally'  pale  and  glossy. 
Esmarch's  bandage  was  applied,  the  external  wound  was  enlarged  to  about  eight  inches, 
the  massive  clots,  some  containing  particles  of  street  dirt,  were  turned  out  of  the 
muscular  interstices,  and  from  between  the  fragments  one  perfectly  detached  piece  of 
the  tibia  was  extracted.  From  the  middle  of  the  main  cavity  into  which  the  frag- 
ments protruded,  a  counter-incision  was  made  backward  through  the  calf  of  the  leg, 
into  which  a  large-sized  drainage-tube  was  placed.     Three  more  counter-incisions,  cor- 


34  RULES  OF   ASEPTIC   AND   ANTISEPTIC  SURGERY. 

responding  to  as  many  recesses,  were  made.  Tlie  torn  artery  could  not  be  found.  A 
large  moist  dressing  was  applied,  and  the  limb  fixed  between  two  well-padded  lateral 
board  si)lints,  held  together  by  a  pure  gum  bandage.  Moderato  oozing  soiled  the 
dressings  somewhat  during  the  following  night,  wherefore  the  elastic  bandage  was 
removed  in  the  morning,  and  the  soiled  parts  of  the  underlying  dressing  were  well 
dusted  with  iodoform.  Another  envelope  of  gauze  was  laid  on  top  of  the  old  dressings 
and  the  splints  were  replaced  and  fastened  with  muslin  bandages.  Jan.  31st. — The 
patient's  temperature  had  not  risen  above  100°  Fahr.,  he  complained  of  very  little  pain, 
no  hemorrhage  had  followed,  the  circulation  of  the  limb  was  good,  hence  the  dressings 
were  not  disturbed  until  this  date.  The  wound  was  found  to  be  in  good  condition  ; 
some  blood-clots  were  still  adherent  to  the  drainage-tubes.  Wound  was  re-dressed  and 
limb  put  up  in  a  solid  plaster-of-Paris  splint.  In  the  beginning  the  dressings  were 
changed  about  weekly;  from  February  1.5th,  every  fortnight.  March  Sd. — After  the 
exuberant  granulations  surrounding  it  had  been  scraped  away,  the  entire  belly  of  the 
tibialis  anticus  muscle  was  found  to  be  of  a  grayish-yellow  color  and  necrosed.  It  was 
not  putrid,  although  a  good  deal  of  secretion  was  present.  The  wound  was  enlarged 
and  the  necrosed  muscle  was  removed.  Thereafter  the  secretion  diminished  materially, 
although  five  sequestra  were  consecutively  rcTuoved.  Consolidation  was  rather  slow, 
but  finally  complete,  so  that  the  patient  was  able  to  walk  without  support  in  Octo- 
ber of  the  same  year.  Shortening  about  one  inch.  If  left  to  themselves,  deep-seated 
and  extensive  contaminated  w'ounds,  presenting  a  small  external  orifice,  are,  for  obvi- 
ous reasons,  most  dangerous.  Free  exposure,  thorough-going  cleansing  and  disinfection, 
together  with  good  drainage,  are  then  imperative. 

2.  Aseptic  Wounds. — The  nature  of  many  wounds  and  their  causation 
are  such  as  to  jHCclude  the  probability  of  contamination.  Most  gunshot 
wounds  and  many  compound  fractures  belong  to  this  class.  In  these  cases 
interference  should  be  very  discreet.  It  should  consist  of  thorough  cleansing 
of  the  integument,  ordinarily  an  aseptic  dry  dressing,  or,  in  case  of  doubt, 
of  superficial  drainage  and  a  moist  dressing,  together  with  reduction  and 
support  and  retention  by  splint  where  a  fracture  requires  it. 

Case. — John  D.,  aged  thirty-two,  December  4,  1885,  sustained  a  compound  com- 
minuted fracture  of  the  upper  half  of  the  tibia  by  a  horse-kick.  Dr.  W.  T.  Kudlich,  of 
Hoboken,  saw  him  immediately  after  the  accident,  cut  off  the  clothing,  disinfected  the 
vicinity  of  the  small  wound,  and  dressed  it  amply  with  iodoform  gauze.  A  temporary 
splint  was  also  applied,  and  probing  or  examination  toas  thoughtfuLlij  refrained  from. 
The  patient  was  brought  to  his  home,  where,  the  next  day,  he  was  anesthetized.  The 
temporary  splint  and  dressings  were  removed,  the  vicinity  of  the  wound  was  carefully 
cleansed  and  disinfected,  and,  vvith  the  observance  of  all  necessary  cautelcB,  a  thorough 
examination  of  the  injury  was  instituted.  A  compound  comminuted  fracture  was  easily 
made  out,  and  three  loose  fragments  of  bone  were  removed.  The  laceration  of  the 
soft  parts  and  ecchymosis  were  found  very  moderate,  and  confined  to  the  tissues  an- 
terior to  the  tibia.  A  couple  of  short  drainage-tubes  were  inserted  into  two  recesses, 
and,  the  wound  being  well  irrigated,  was  enveloped  in  a  moist  dressing.  The  limb 
was  put  up  in  a  solid  plaster-of-Paris  splint,  with  the  knee  bent  at  an  obtuse  angle, 
and  was  suspended  from  a  frame. 

The  temperature  remained  normal  or  almost  noi-mal  throughout. 

Dec.  18th. — Appearance  of  wound  normal.  Moderate  secretion  due  to  limited 
necrosis  of  a  loose  fragment  of  bone.  Dec.  28th. — Second  change  of  dressings.  Ex- 
uberant granulations  have  filled  up  the  defect.     Jan.  18th. — A  fenestrated  silicate-of- 


THE  TEEATMENT  OF  ACCIDENTAL  WOUNDS.  35 

soda  splint  was  applied.  The  secretion  continued  to  be  scanty.  In  May  consolidation 
was  perfect,  but  a  small  sinus  remained  until  October,  when,  after  the  extraction  of 
several  small  spicula  of  bone,  definitive  healing  of  the  wound  ensued.  'So  appreciable 
shortening  resulted. 

Note. — In  the  more  extensive  injuries  of  the  extremities  caused  by  crushing  force,  the 
gravity  of  the  case  hinges  more  upon  the  extent  of  the  injury  to  the  soft  parts  than  to  the  bones. 
A  compound  fracture  by  direct  force — for  instance,  the  blow  of  a  hammer  upon  the  tibia,  where 
the  crushing  and  laceration  of  the  soft  parts  are  comparatively  limited — is  by  far  not  as  dangerous 
as,  for  instance,  the  stripping  off  of  the  entire  integument  of  the  lower  extremity,  or  the  crush- 
ing and  pulpification  of  the  large  muscles,  vessels,  and  nerves  situated  on  the  anterior  and 
internal  aspect  of  the  thigh,  though  these  latter  injuries  be  uncomphcated  with  fracture.  The 
shock  and  the  presence  of  extensive  thrombosis,  in  addition  to  the  fact  that,  with  the  large  quan- 
tity of  mortified  tissues,  preservation  of  the  aseptic  state  is  extremely  uncertain  and  difficult, 
class  these  injuries  among  the  most  grave  and  dangerous. 

3.  Gunshot  Wounds. — The  fact  that  most  fresh  gunshot  woiinds  are  asep- 
tic has  been  pointed  out  by  Esmarch,  and  is  now  -well  established.  Reyher 
and  Bergmann's  experiences  in  the  Eusso-Turkisli  war  put  the  fact  beyond 
controversy. 

Wise  precaution  against  infecting  a  fresh  gunshot  wound  will  be  richly 
rewarded  by  excellent  results.  In  most  cases  cleansing  and  disinfection  of 
the  skin  in  the  vicinity  of  the  points  of  entrance  and  exit,  together  with  a 
dry  dressing,  will  be  sufficient.  If  the  case  is  complicated  by  fracture,  a 
suitable  splint,  preferably  plaster  of  Paris  (Bergmann),  shotild  be  added. 

If  the  course  is  free  from  septic  fever  and  suppuration,  this  will  be  mani- 
fest within  the  first  three  or  four  days ;  in  that  case,  the  first  dressing  and 
the  splint  can  be  left  undisturbed  for  the  length  of  time  required  for  the 
accomplishment  of  bony  union. 

Flesh-wounds  will  be  healed  within  a  fortnight  or  three  weeks.  Gun- 
shot fractures  will  require  a  longer  time  for  healing  and  consolidation,  but 
are  in  no  way  diiferent  from  ordinary  compound  fractures. 

The  projectile  will  cause  very  little  or  no  irritation  in  aseptic — that  is, 
non-suppurating — gunshot  wounds.  Generally  it  will  become  encysted. 
Search  for  the  projectile  in  the  bottom  of  the  wound  is  rarely  indicated. 
It  can  occur,  however,  that  pressure  of  a  projectile  or  its  fragment,  or  a 
sharj)  s^Dicultim  of  bone  on  a  nerve-trunk,  may  necessitate  search  and  extrac- 
tion.    This  must  be  done  under  careful  asepsis. 

It  is  even  not  necessary  to  remove  a  projectile  lodged  under  the  skin. 
It  will  do  no  harm  if  left  there  itntil  the  channel  which  it  cut  by  its  passage 
through  the  tissues  is  obliterated,  when  its  removal  by  incision  can  not  lead 
to  an  infection  of  the  bullet-track. 

In  cases  of  injury  to  large  vessels  or  the  intestines,  immediate  interfer- 
ence can  not  be  delayed,  but  should  be  carried  out  under  most  rigid  anti- 
septic precautions. 

Note. — Recent  successes  (W.  T.  Bull)  achieved  by  immediate  laparotomy  and  suture  of  the 
wounded  iatestines  justify  the  procedure. 

Where  the  nature  of  the  charge  or  the  short  distance  from  which  the 
shot  was  delivered  makes  the  entrance  of  a  gun-wad  probable,  or  where  the 


36  RULES  OF  ASEPTIC   AND  ANTISEPTIC  SURGERY. 

examination  of  the  superjacent  clothing  shows  a  large  defect,  rendering  the 
probability  great  that  shreds  of  soiled  cloth  have  been  carried  to  the  bottom 
of  the  wound,  dilatation,  search,  and  extraction  may  be  indicated.  But  it 
is  better  to  w^ait  in  cases  of  doubt,  as  even  these  foreign  substances  may 
become  encysted  and  harmless. 

Should  suppuration  follow,  the  patient  will  not  be  worse  off  than  if  a 
fruitless  search  had  been  made  at  the  outset,  and  the  use  of  the  suppurating 
track  as  a  guide  will  materially  facilitate  the  finding  of  the  irritating  body. 

XoTE. — Reyher's  observations  (Yolkmann's  "  Sammlung,"  Nos.  142,  143,  1878)  may  serve  as 
a  fair  sample  of  the  radical  change  that  has  taken  place  in  the  results  of  the  treatment  of  gun- 
shot fractures. 

Gunshot  fracture  of  the  knee-joint  was  formerly  considered  an  indication  for  immediate 
amputation.  Reyher  treated  eighteen  fresh  cases  aseptically — that  is,  by  simply  cleansing  and 
disinfecting  the  skin  about  the  wound,  and  occluding  the  same  by  an  antiseptic  dressing.  Where 
the  wound  was  gaping,  or  where  there  was  ground  to  suspect  the  entrance  of  dirt  or  shreds  of 
clothing  into  the  bullet-track,  dilatation,  irrigation,  and  extraction  of  the  foreign  body,  with  sub- 
sequent drainage,  was  practiced  before  the  wound  was  sealed  up.  Of  these  eighteen  cases,  fif- 
teen recovered,  with  movable  knee-joints — 83"3  per  cent  of  recoveries.  One  patient  died  of 
fatty  embolism  in  twenty-four  hours  after  the  injury ;  another  of  haemorrhage  from  the  divided 
popUteal  artery  and  vein  on  the  fifth  day ;  and  the  third  one  of  pysemia. 

Of  nineteen  that  came  under  his  care  several  days  after  the  reception  of  the  injury,  with 
well-established  suppuration,  eighteen  died,  and  one  recovered  with  a  stiff  joint.  In  spite  of  an 
energetic  antiseptic  treatment  by  incisions,  drainage,  and  irrigation,  a  mortality  of  85  per  cent 
was  noted. 

Of  twenty-three  that  were  not  subjected  to  any  form  of  antiseptic  treatment,  twenty-two 
died,  one  survived,  a  mortality  of  95"6  per  cent — clearly  justifying  the  practice  of  the  older  sur- 
geons, who  at  once  performed  amputation  in  cases  of  gunshot  fracture  of  the  knee-joint. 

Infected  accidental  wounds  or  gunshot  injuries  that  become  the  seat  of 
suppuration  can  be  classed  under  the  heading  of  phlegmonous  processes,  and 
their  treatment  will  be  dealt  with  in  a  subsequent  chapter. 


CHAPTER   V. 
SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD. 

A.   General  Principles. 

L     TECHNIQUE    OF    SURGICAL    DISSECTION. 

Modern  surgery  demands  that  the  invasion  of  the  uninflamed  tissues 
of  the  human  body  by  the  surgeon's  knife  should  be  surrounded  by  all  the 
safeguards  that  are  known  to  be  effective  in  preventing  suppuration.  The 
mortality  following  operations  sanctioned  by  pre-antiseptic  surgery  has  been 
remarkably  depressed  by  a  conscientious  and  intelligent  adherence  to  the 
principles  of  surgical  cleanliness.  A  large  number  of  recently  devised  use- 
ful operations  have  become  legitimate  under  the  assumption  that  suppura- 


SPECIAL  APPLICATION  OF  THE   ASEPTIC  METHOD. 


37 


tion  can  be  excluded.  The  cranium,  large  joints,  the  tendinous  sheaths, 
and  the  peritoneal  cavity  are  now  safely  accessible  for  curatiye  or  even  diag- 
nostic purposes. 

The  statement  that  a  real  observance  of  asepticism  offers  a  sure  guaran- 
tee against  suppuration,  be  the  performance  of  a  bloody  operation  however 
clumsy,  rough,  and  unskillful,  is  true,  but  can  not  be  pleaded  as  an  excuse 
for  the  absence  of  that  equipment  of  pathological  and  anatomical  knowledge 
and  technical  skill  which  go  toward  forming  a  good  surgeon.  Although 
the  general  standard  of  safety  and  success  in  surgery  has  been  considerably 
raised,  excellence  will  be  attained  by  those  only  who  unite  the  qualities  of 
a  good  diagnostician,  pathologist,  and  anatomist  with  the  tact,  energy,  and 
technical  skill  of  the  accomplished  surgeon. 

The  technique  of  surgical  dissection  is  based  upon  principles,  the  ob- 
servance of  which  enables  us  to  safely  explore  and  manipulate  any  accessible 
part  of  the  human  body. 

Aside  from  the  ever-present  desideratum  of  preventing  infection,  the 
avoidance  of  accidental  injury  of  important  organs  and  the  control  of  hsem- 
orrhage  first  deserve  attention. 

The  'principle  of  doing  every  step  of  cm  operation  under  the  guidance  of 
the  eye,  is  the  most  important  discipline  of  dissection  to  he  acquired.  It 
should  never  be  sacrificed  without  the  most  stringent  necessity.  Its  non- 
observance  is  the  source  of  most  that  is  embarrassing,  appalling,  and  dis- 
astrous in  operative  work. 

Upo7i  this  principle  is  iased  the  rule  to  always  mahe  an  ample  and  ade- 
quate incision,  which  should  be  gradually  deepened  layer  by  layer,  until 
the  part  sought  after  is  freely  exposed. 


Fig.  10. — a,  Bellied  scalpel  for  cutaneous  incision,     b,  Sharp-pointed  scalpel  for  deeper  dissection. 

For  the  cutaneous  incision  a  bellied  scalpel,  held  like  a  fiddle-bow,  is 
the  most  useful.  A  careful  and  clean  incision  will  insure  a  lineal  cicatrix. 
As  soon  as  the  skin  is  divided,  the  subcutaneous  vessels  will  become  visible. 
If  they  are  crossing  the  line  of  incision,  they  should  be  grasjDed  between 

two  artery  forceps,  divided 
between,  and  safely  tied 
off  with  catgut.  In  cut- 
ting through  the  fascia,  the 
grooved  director  used  to  play 
an  important  part  in  for- 
mer times.     Its  use  has  been 

11. — Manner  of  holdino'  the  knife  for  the  cutaneous  t       ,     -,    -i  _e  t 

incision.  "(Esmarch.;  Supplanted  by  a  sater  mode 


Tig, 


38 


RULES  OF  ASEPTIC   AND  ANTISEPTIC  SURGERY. 


of  preparation,  known  as  cutting  between  two  thumb-forceps.  The  author 
once  observed  that,  in  thrusting  a  grooved  director  underneath  the  fascial 
coverings  of  a  hernia,  the  hernial  sac  was  opened,  and  the  adherent  gut 
nearly  torn  through.  As  it  was,  only  its  serous  covering  was  lacerated.  In 
another  instance,  puncture  of  the  deep  jugular  vein  by  the  point  of  the 
grooved  director  happened,  and  led  to  very  annoying  haemorrhage  from  the 
deepest  parts  of  the  wound,  which  made  exposure  and  ligature  of  the  injured 
vein  very  difficult.  It  may  be  said  that,  unless  very  thin  layers  are  taken 
up  by  the  grooved  director,  the  surgeon  never  can  tell  beforehand  what  he 
is  going  to  cut  through  while  using  it.  Veins  especially  are  easily  injured, 
as,  being  put  on  the  stretch,  they  become  empty.  Stretched,  they  lose 
their  identity  to  the  eye,  and  look  exactly  like  ordinary  connective  tissue. 


Fig.  12.  Fio.  13. 

Securing  and  tying  vessels  traversing  the  line  of  incision. 

Cutting  between  two  forceps  has  the  peculiarity  that,  a  thin  layer  of 
tissue  being  raised  before  each  cutting,  air  enters  into  and  rarefies  its  meshes, 
rendering  clearly  visible  the  vessels,  which  can  be  easily  isolated  and  secured 
before  they  are  cut.  From  this  result  two  very  great  advantages  :  First, 
the  patient  does  not  lose  one  drop  of  blood  from  a  vessel  secured  previous 
to  its  division  ;  and  last,  but  not  least,  the  wound  remains  dry  and  clean. 
No  time  is  lost  in  hunting  for  a  retracted  vessel  in  a  pool  of  blood,  there 
is  no  occasion  for  hast}^  and  rough  sponging,  and  everybody  preserves  an 
even  tenor  of  mind  very  essential  to  success. 

The  advice,  so  often  met  with  in  text-books,  that  the  knife  should  be 
laid  aside  where  the  tissues  are  loose,  and  that  tearing  or  scraping  with  for- 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD. 


39 


ceps  or  the  finger-nail  is  safer,  is,  to  say  the  least,  very  questionable.  This 
advice  is  born  of  the  fear  of  unexpected  hsemorrhage,  which,  however,  can 
be  always  avoided  by  cutting  between  two  forceps.  The  beginner,  especially, 
is  prone  to  carry  this  mode  of  blunt  preparation  to  great  lengths,  and  lacer- 
ation of  large  veins,  the  peritoneum,  or  cysts  is  the  result. 


Fig 


Cutting  between  two  thumb-forceps.     (Esmarch.) 


A  consideration  of  no  small  importance  is  the  fact  that  a  clean-cut  wound 
will  sometimes  heal  in  spite  of  some  local  reaction  and  fever.  This  means, 
that  the  blood-  and  lymph- vessels  of  the  parts  concerned  being  not  much 
bruised,  sufficient  nutriment  is  carried  to  the  walls  of  the  wound  to  over- 
come a  moderate  degree  of  micrococcal  infection.  Where  the  nutrition  of 
the  parts  is  seriously  interfered  with  by  tearing  and  bruising  pertinent  to 
blunt  dissection,  a  much  higher  degree  of  asepticism  is  required  to  secure 
absence  of  suppuration. 

Note. — The  old  surgical  tenet,  that  torn  and  bruised  operative  wounds  ai^e  not  prone  to  heal 
kindly,  is  based  upon  the  fact  that  devitalized  tissues  form  an  especially  favorable  pabulum  to 
microbial  development.  The  observation  that  very  well  nourished  tissues,  as,  for  instance,  those 
of  the  face,  will  heal  readily  under  almost  all  circumstances,  and  without  the  observance  of  anti- 
septic precautions,  is  explained  by  the  fact  that  they  are  very  well  vascularized,  and  a  rich  supply 
of  oxygenated  blood  is  one  of  the  strongest  gennicides.  We  often  saw  the  parts  become  red, 
swollen,  and  painful,  and  were  expecting  suppuration,  but  in  vain,  as  all  the  local  symptoms  and 
the  fever  receded,  and  good  union  followed. 

As  the  wound  is  gradually  deepened,  sharp  or  blunt  retractors  should 
be  employed  to  well  expose  to  view  its  bottom,  in  which  is  centered  the  sur- 
geon's interest.  The  skin,  muscles,  fasciae,  tendons,  or  the  periosteum  can 
be  held  back  by  sharp  retractors  ;  vessels  and  nerves,  the  |)eritoneum,  and 
friable  glands  or  cysts  should  never  be  hooked  up  by  them,  blunt  retractors 
deserving  the  preference. 

Most  of  the  retractors  commonly  sold  by  the  instrument-dealers  are 


40 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


worthless.  A  useful  retractor  must 
have  a  good,  ample  curve,  a  propor- 
tionate and  safe  grasp,  a  smooth,  solid 
handle,  and  a  strong  shank,  so  as  to 
be  able  to  sustain  a  good  deal  of  press- 
ure without  bendins;  or  breaking. 


Fig.  15.— Small 
blunt  retractors. 


Fig.  16. — Medium-sized  blunt 
retractor,     a,  Actual  size. 


Fig.  17. 


-Large-sized  blunt  retractor, 
h.  Actual  size. 


Fig.  10. — Large  four-pronged  sharp  retractor  (Volkmann). 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD. 


41 


Fig.  20. — Manner  of  holding  the  knife 
for  deep  dissection.     (Esmarch.) 


The  shapes  and  sizes  most  useful  for  general  surgical  work  are  depicted 
by  Figs.  15,  16,  17,  18,  and  19. 

The  deeper  the  knife  penetrates,  the  nearer  it  approaches  important 

organs,  the  shallower  its 
strokes  should  become. 
A  somewhat  pointed 
scalpel  should  be  used, 
and  its  strokes,  especial- 
ly where  they  sever  dense 
tissues,  should  be  made 
with  the  very  point  of  the 
instrument,  which  should 
be  held  like  a  pen,  but 
rather  steeply. 
Use  of  the  grooved  director,  or  the  scissors,  or  the  sichleshaped  bistoury 
in  the  bottom  of  a  deep  wound  is  always  unsafe,  as  it  may  lead  to  unex- 
pected haemorrhage  or  something  worse.  Especially  dangerous  is  the  last- 
named  instrument,  as  its  very  nature  renders  impossible  the  observance  of 
the  principle  of  not  cutting  what  we  do  not  see.  It  cuts  from  within  out- 
ward, takes  up  unseen  tissues,  and  may  become  the  cause  of  unnecessary 
trouble  and  embarrassment. 

Should  it  become  evident,  as  the  wound  deepens,  that  the  first  incision 
is  inadequate,  and  that,  in  order  to  afford  access,  its  edges  must  be  subjected 
to  severe  tension,  and  that  work  is  thereby  cramped,  an  extension  of  the 
first  incision  is  in  order.  This  should  be  done  methodically  from  without 
inward  until  the  wound  is  sufficiently  enlarged. 

Note. — The  author  once  saw  an  ovariotomist  make  abdominal  section  with  exaggerated 
minuteness,  layer  by  layer,  until  the  belly  was  opened,  tying  each  small  vessel  as  it  was  exposed. 
When  a  digital  exploration  had  made  evident  the  insufficiency  of  the  incision,  he  enlarged  it  by 
cutting  through  the  entire  thickness  of  the  abdominal  wall  loith  a  stout  pair  of  scissors  at  one  stroke. 
Of  course  the  incision  was  uneven,  some  layers  being  further  cut  than  others,  haemorrhage  was 
considerable,  and  finding  and  securing  of  the  retracted  vessels  not  easy. 

The  shape  of  every  operation  wound  should  be  such,  if  possible,  as  to 
afford  the  best  conditions  of  access, 
and,  later  on,  for  natural  drainage. 
The  funnel  shape  (Fig.  21,  a)  is 
meant  by  this — that  is,  that  the  first 
incision  should  be  the  longest,  the 
next  one  a  little  shorter,  the  last  one 
the  shortest.  Even  if  no  drainage- 
tube  is  inserted  in  such  a  wound,  as 
long  as  the  closing  stitches  are  not 
too  tight  and  too  many,  the  interstices  of  the  suture  will  afford  ample 
drainage. 

Bottle-shaped  wounds  (Fig.  31,  b)  are  disadvantageous  in  every  way. 
They  result  from  a  too  small  cutaneous  incision,  are  uncomfortable  and 


FiQ.  21. — A,  Funnel-shaped  wound, 
shaped  wound. 


B,  Bottle- 


42 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


unsafe  during  the  operation,  and  after  closure  offer  poor  conditions  for 
natural  drainage.  They  alwaA^s  require  a  drainage-tube,  and,  even  with  a 
tube,  if  not  absolutely  aseptic,  become  a  very  hot-bed  of  suj)puration,  as  the 
discharges  of  infected  recesses  may  not  find  ready  egress. 

Where  the  incision  must  be  carried  through  condensed  or  i7ijlamed  tis- 
sues, preparation  between  two  forceps  will  be  generally  impossible.  All 
the  more  stress  should  be  laid  upon  the  amplitude  of  the  first  cut,  and  upon 
the  adequate  dilatation  of  the  wound  by  serviceable  and  solid  retractors.  As 
the  wound  deepens,  the  hooks  should  be  alternately  released  and  inserted 
deeper,  so  as  to  follow  up  closely  the  work  of  the  knife. 

On  account  of  their  hypersemic  state  and  density,  haemorrhage  will  be 
found  a  great  deal  more  profuse  in  inflamed  than  in  normal  tissues.  The 
presence  of  vessels  will  become  manifest  only  by  the  haemorrhage  caused  in 
cutting  them.  The  smaller  arteries  can  be  easily  controlled  by  increasing 
the  tension  exerted  by  the  retractors  on  the  edges  of  the  wound.  Larger 
vessels  must  be  tied  off.  But  the  density  and  often  the  brittleness  of  the 
tissues  prevent  grasping  of 
the  bleeding  points  with 
artery-forceps,  hence  an- 
other expedient  must  be 
used. 

An  ordinary  curved,  or, 
better,  a  perfectly  round 
haemostatic  needle,  armed 
with  catgut,  is  carried  with 
a  needle-holder  through  the 
tissues  adjacent  to  the  bleed- 
ing point  in  two  or  three 

stitches,  so  as  to  surround  it  like  a  purse-string.  Being  tied,  it  closes  the 
bleeding  orifice. 


Fig.  22. 

Haemostatic 

needle. 


Fig.  23. 


Manner  of  applying  haemostatic 
needle  (Esmarcli). 


When  a  plexus  of  considerable  vessels,  especially  veins,  is  encountered 
in  the  bottom  of  a  wound,  or  where,  for  some  reasons,  it  is  desirable  to 
hasten  operative  work,  the  employment  of  mass  ligatures  will  be  found  an 
expedient  and  safe  way  to  rapid  progress. 

ThierscJi's  spindle  and  forceps  is  an  invaluable  apparatus  for  applying 
mass  ligatures  to  dense  tissues  in  difficult  and  deep  situations.  A  blunt, 
probe-pointed,  curved  needle  and  a  straight  ivory  spindle,  armed  with  stout 
silk  or  catgut,  and  an  appropriate  forceps,  make  up  the  apparatus.     The 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD. 


43 


probe-pointed  needle  is  grasped  by  the  beak  of  the  forceps,  and  is  cau- 
tiously insinuated  under  the  plexus  or  mass  to  be  tied  off.  Veins  and 
arteries  are  not  apt  to  be  injured  by  the  blunt  point,  as  they  are  inclined 
to  slide  off  from  it.  As  soon  as  the  ligature  thread  is  drawn  through  under 
the  mass,  a  knot  is  made,  and,  the  spindles  serving  as  solid  handles,  it  can 
be  tightened  with  a  great  deal  of  firmness  and  security.  The  mass  can  be 
safely  divided  between  two  of  these  ligatures. 

The  treatment  of  veins  in  operative  wounds 
is  similar  to  that  applied  to  arteries.  There  are 
some  points,  however,  that  constitute  an  impor- 
tant difference,  and  deserve  special  attention.  The 
tension  exercised  by  retractors  is  very  apt  to  ob- 
literate the  normal  characteristics  of  veins.  The 
dark  blood  they  contain  is  driven  out  of  them, 
and  they  can  not  be  distinguished  from  ordinary 
connective  tissue.  Especially  in  blunt  prepara- 
tion, lacerations  of  veins  are  apt  to  occur  and 
cause  serious  difficulty.  To  find  a  bleeding  vein 
is  not  as  easy  as  to  locate  an  injured  artery,  readily 
marked  by  its  Jet  of  blood.  And,  even  if  the 
bleeding  point  is  recognized,  it  is  not  always  easy 
to  stop  a  torn  vein,  as  the  laceration  may  be,  and 
in  fact  frequently  is,  an  irregular  and  extensive 
slit.  On  the  other  hand,  venous  hasmorrhage  can 
often  be  effectively  checked  by  simple  pressure  or 
plugging.  If  the  finding  of  a  torn  and  retracted 
vein  should  be  difficult  and  involve  too  much 
time,  it  will  be  found  a  good  expedient  to  plug 
up  the  place  from  which  the  haemorrhage  issues 
with  a  strip  of  iodoformed  gauze,  held  in  place 
by  light  finger-pressure  until  coagulation  occurs. 
Formerly  the  author  used  a  bit  of  sponge  for  this 
purpose,  but  the  following  experience  has  shown  that  sponge  is  not  a  safe 
material : 

Case. — Theresa  Kops,  housewife,  aged  forty-eight.  February  10,  1883. — Ampu- 
tation of  left  breast,  with  evacuation  of  the  contents  of  the  axilla  for  scirrhus  of  the 
mammary  gland.  Wound  sutured  throughout ;  drainage  by  counter-incision  through 
latissimus  dorsi.  Aseptic  dressing.  After  feverless  course,  first  change  of  dressings 
on  February  21st,  when  the  wound  was  found  united.  Drainage-tube  was  withdrawn. 
Feb.  22d. — Severe  chill,  phlegmonous  infiltration  of  axillary  region.  Feb.  23d. — Incis- 
ion through  cicatrix,  and  evacuation  of  a  large  quantity  of  pus,  followed  by  a  small 
fragment  of  sponge;  drainage.  Uninterrupted  healing  of  the  axillary  abscess  by 
granulation. 

In  removing  the  axillary  glands  a  small  vein  was  put  on  the  stretch, 
and,  being  ruptured,  retracted  so  far  that  it  could  not  be  found.  A  good- 
sized  sponge  was  stuffed  temporarily  into  the  recess  from  which  the  hsemor- 


FiG.  25. — Thiersch's  spindle 
apparatus. 


44  RULES  OF  ASEPTIC  AND   ANTISEPTIC  SURGERY. 

rhage  issued,  and  the  operation  was  finished.  When  the  sponge  was  ex- 
tracted, it  came  away,  as  usual,  with  some  resistance,  due  to  the  matting 
of  the  blood-clot  into  its  meshes.  The  sponge  was  a  very  soft  and  brittle 
one,  and  its  own  cohesion  was  apparently  less  than  the  cohesion  of  its 
surface  to  the  tissues  matted  to  it.  A  small  portion  of  the  sponge  tore  off 
and  was  left  behind  in  the  wound.  It  caused  no  trouble  for  eleven  days, 
and  only  after  the  disturbance  of  its  relations  by  the  removal  of  the  drain- 
age-tube did  its  decomposition  set  in.  Since  that  time  a  strip  of  iodoformed 
gauze  was  used  for  the  mentioned  purpose  by  the  author,  which  would  not 
tear,  and  could  not  be  overlooked,  as  its  end  is  carried  out  of  the  wound 
for  a  mark. 

Close  attention  to  the  details  enumerated  above  will  secure  a  dry  and 
easily  accessible  wound,  '^o  sudden  and  uncontrollable  haemorrhage  will 
occur  to  create  flurry  or  alarm  ;  no  embarrassment  will  cause  undue  haste 
or  an  ill-considered  move  ;  the  patient  will  fare  well,  as,  even  with  the  seem- 
ing deliberation,  the  operation  will  be  speedily  accomplished,  and,  what  is 
the  main  thing,  no  unnecessary  loss  of  blood  will  be  sustained. 

n.     SUTURES. 

Primary  union  with  a  linear  cicatrix  is  the  ideal  of  the  healing  of  an 
aseptic  wound.  As  it  depends  to  a  great  measure  upon  an  exact  coaptation 
of  its  edges  in  such  a  manner,  that  circulation  of  the  integument  should  not 
be  interfered  with,  and  as  exact  coaptation  under  varying  circumstances 
requires  a  variation  of  the  procedure,  a  discussion  of  the  important  differ- 
ences in  the  technique  of  suturing  may  receive  some  consideration. 

Exact  coaptation  of  the  corresponding  points  of  the  edges  of  the  wound 
by  finger-pressure  or  otherwise,  before  and  tohile  j^^ssing  the  stitch,  is  the 
first  condition  of  a  true  suture.  Where  there  is  no  considerable  loss  of 
integument,  and  where  the  edges  of  the  wound  are  ecpially  thick  and  have 
sufficient  body,  this  can  be  done  easily  by  compressing  the  edges  between 
the  index  and  thumb  until  they  touch  on  the  same  level,  A  good-sized 
curved  needle  is  then  jDassed  through  both  edges  of  the  wound,  which 
will  be  retained  in  their  correct  relation  by  simply  tying  the  catgut 
thread. 

Where  one  of  the  edges  is  thick  and  the  other  rather  thin,  coaptation 
is  more  difficult,  as  the  thinner  edge  is  apt  to  slip  back,  leaving  a  portion 
of  raw  surface  exposed.  Or  where  both  edges  of  the  wound  are  thin,  as, 
for  instance,  on  the  neck,  the  scrotum,  and  the  dorsum  of  the  hand  or 
foot,  they  have  the  tendency  to  curl  under,  raw  being  in  contact  with  epi- 
dermidal  surface.  Both  of  these  relations  will  produce  an  uneven  line  of 
suture,  and  will  frustrate  exact  primary  union.  Partial  healing  by  granula- 
tion is  then  unavoidable. 

Under  these  circumstances  the  best  result  will  be  achieved  by  the  fol- 
lowing plan  :  The  edges  of  the  wound  are  brought  togetlier  and  pinched 
up  by  index  and  thumb  in  such  a  way  as  to  form  a  continuous  ridge,  on 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.  45 


the  top  of  which  should  appear  the  line  of  incision.     A  straiglit  needle  is 
thrust  transversely  through  the  base  of  this  ridge,  and  the  suture  is  tied 
while  the  fingers  still  retain  their  position.     The  appearance  of  the  com- 
pleted- suture  is  rather  grotesque  ;  but, 
when  the  stitches  are  absorbed  or  re- 
moved, the  peculiar-looking  ridge  will 
flatten  out  spontaneously,  and  the  re- 
sult will  be  a  beautiful  fine  cicatrix. 
See  Figs.  26  and  27. 

In  tying  a  surgical  knot,  a  certain 
little  knack  will  be  found  extremely 
useful,  especially  where  good  assist- 
ance can  not  be  had.  It  consists  in 
Jamming  down  the  first  or  double  cast 
into  the  angle  of  the  suture  nearest  to 
the  operator  by  a  slight  Jerk,  made  upon  the  distal  end  of  the  thread,  while 
the  mesial  one  is  held  steadily  on  the  stretch.  This  Jamming  of  the  catgut 
will  be  Just  sufficient  to  hold  the  edges  of  the  wound  together,  until  with 

the  second  cast  the  knot  is 


Fig.  26. 


tied.  It  will  even  hold  to- 
gether edges  approximated 
with  some  degree  of  force. 

Where  there  is  much  loss 
of  integument,  as  in  many 
cases  of  breast  amputation, 
or  where  the  sutures  may 
have  to  stand  a  good  deal  of 
strain,  as,  for  instance,  the 
abdominal  stitches  after  ova- 
riotomy, aside  from  the  su- 
tures of  coaptation  above 
mentioned,  supporting  or  re- 
tentive sutures  are  necessary. 
They  have  to  embrace  a 
good  deal  more  integument 
than  the  finer  stitches,  and 
should  be  inserted  from  one 
half  to  two  inches  away  from 
the  edges  of  the  wound.  Lat- 
eral concentric  pressure  by  the  hands  of  an  assistant  will  very  much  facili- 
tate the  proper  placing  of  these  sutures. 

They  can  be  made  in  several  ways.  The  simplest  one  is  to  pass  three 
or  four  or  more  interrupted  catgut  sutures  of  wider  scope,  and  then  to  tie 
them  while  the  edges  of  the  wound  are  firmly  supported  by  an  assistant 
(Fig.  28).  The  required  number  of  finer  stitches  is  passed  afterward.  An- 
other good  way  is  the  application  of  a  mattress  suture,  illustrated  in  Fig. 


,.      '^x 


Fig.  27. 


46 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


29,  combined  with  a  continuous  coaptation  suture,  all  done  with  one  piece 
of  catgut. 

Where  silver  wire  or  silkworm -gut  are  available,  the  quill  suture  or 
Lister's  button  suture  will  give  much  satisfaction.     Both  of  these  forms  of 


Fig.  28. — a.  Interrupted  retentive  suture. 


Fig.  29. — Combined  mattress  suture  and  Glover': 
stitch. 


retentive  suture  will  be  very  proper  after  abdominal  operations.  For  the 
quilled  suture,  small  cylindrical  pieces  of  well-disinfected  wood  will  answer. 
Buttons  for  Lister's  retentive  suture  (Fig.  30)  are  cut  out  of  stout  sheet 
lead  with  a  pair  of  scissors.  It  is  sold  by  dental-supply  traders  under  the 
name  of  "suction  lead."     The  wire  or  gut  is  ai'med  with  a  perforated  shot. 


a    « 


^i^^'^""""" — t" 


a[  ^ 


Fig.  30. — a.  Plate  and  sliot  suture. 
b.  Interrupted  suture. 


Fig.  31. — a.  Catgut  suture  from  suppurating  stitch- 
hole,  b.  Catgut  from  sweet  stitch-hole,  nearly 
absorbed. 


which  is  clamped  to  its  end  ;  over  this  is  slipped  a  button.  The  suture  is 
passed,  and  the  needle  is  unthreaded.  Over  the  second  end  a  button  and 
shot  are  slipped,  the  stitch  is  tightened,  and  the  shot  is  clamped. 

In  uniting  more  extensive  wounds,  it  is  better  to  commence  at  the  mid- 
dle and  not  at  the  angle,  as  the  latter  way  may  result  in  uneven  distribu- 
tion and  puckering. 

After  abundant  trial  and  comparison,  the  conclusion  was  arrived  at  by 
the  author  that,  as  a  rule,  the  interrupted  suture  is  in  every  way  preferable 
to  the  continuous  one.     The  exceptions  are  mentioned  at  the  pro23er  place. 

The  chief  advantage  claimed  for  the  continuous  suture — namely,  the 
saving  of  time — is  Illusory.  As  regards  safety  in  holding  and  exactitude 
of  adaptation,  the  interrupted  suture  has  no  peer. 


Secondary  Suture. — Kocher  and  Bergmann  laave  taught  us  to  combine  the  advan- 
tages of  the  open  treatment  with  those  of  the  suture  of  wounds.  Where  it  is  deemed 
unsafe,  for  various  reasons,  to  close  a  wound  at  once  by  suture,  the  wound  is  packed 
from  the  bottom  with  iodoform  gauze.  A  suitable  number  of  silk-worm  gut  or  silver 
wire  stitches  are  then  passed  through  the  edges  of  the  wound.     They  are  not  closed. 


SPECIAL   APPLICATIOX   OF   THE   ASEPTIC   METHOD,  47 

but  their  ends  are  fastened  together  and  arranged  alongside  of  the  wound,  which  is 
dressed  as  usual.  Thus  the  escape  of  the  serous  discharges  is  absolutely  unimpeded, 
and  no  retention  can  take  place.  On  the  fourth  day  the  packing  is  removed,  and,  by 
the  aid  of  the  stitches  left  in  situ,  the  wound  is  closed,  provided  that  its  condition 
is  sweet.  TTounds  treated  thus  behave  like  fresh  ones,  and  usually  heal  by  agglu- 
tination. 

Secondary  sutures  are  used  with  great  advantage,  also,  for  hastening  the  closure  of 
■widely  gaping  wounds. 


Fig.  32. — Perforated  rubber  drainacre-tube. 


in.    DRAINAGE. 

Small  aseptic  "wouncls  of  a  favorable,  that  is  funnel  shape,  do  not  re- 
quire drainage  by  rubber  tubing.  As  few  stitches  should  be  taken,  how- 
ever, as  possible,  to  permit  the  escape  of  the  oozing  between  them.  Small 
wounds  of  bottle  shape  ■will  do  very  well  with  a  narrow  strip  of  iodoform 
ganze  placed  in  one  angle  for  capillary  drainage,  which  should  be  renewed 
on  the  third  day.  Larger  wounds,  especially  those  with  a  sinuous  cavity, 
require  di'ainage  by  rubber  tubing. 

Before  using  the  tube,  a  number  of  oval  holes  should  be  clipped  out  of 
its  side. 

"Through  drainage,"  with  a  view  to  subsequent  irrigation,  is  best 
efEected  by  placing  the  mesial  end  of  the  tube  Just  within  the  cavity  to 

be  drained.  Drawing 
a  long  i^iece  of  tubing 
transversely  through  the 
cavity  does  not  afford 
the  best  conditions  for 
thorough  irrigation,  as 
the  bulk  of  the  irrigating  stream  will  pass  directly  through  the  tube  with- 
out entering  the  cavity  at  all.  Where  two  or  more  short  pieces  of  tubing 
are  placed  just  within  the  cavity,  the  entire  mass  of  the  iiTigating  stream 
is  thrown  into  the  cavity,  to  escape  through  the  opposite  opening  only  after 
having  washed  the  entire  extent  of  its  interior. 

Aseptic  rubber  tubes  never  cause  "irritation."  Increased  discharge  or 
irritation  of  any  kind  is  due  to  infection  introduced  into  the  wound  by 
means  of  the  tube  at  change  of  dressings.  If  the  withdrawn  tube  is 
touched  by  unclean  hands  and  is  then  reintroduced,  it  is  ajjt  to  cause  irrita- 
tion. But  it  is  not  the  tube  but  the  dirt  adhering  to  it  that  is  the  cause  of 
the  trouble. 

The  persistence  of  sinuses  after  certain  operations,  notably  exsections, 
was  also  attributed  to  the  use  of  drainage-tubes.  This  mistake  is  now  ex- 
plained by  the  knowledge,  that  the  sinuses  in  question  do  not  heal  on 
account  of  reinfection  by  tubercle  bacilli,  extending  along  the  tubes  with  the 
discharges  from  an  incompletely  evacuated  tubercular  focus. 

In  aseptic  wounds,  the  oflfice  of  the  drainage-tube  is  performed  by  about 
the  end  of  twenty-four  hours  after  the  ojDeration.  But  other  considerations, 
notably  the  unwilling-ness  of  disturbing  the  rest  of  the  wound  and  of  the 


48  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

patient,  make  it  inexpedieut  to  reopen  the  dressings  so  soon  for  the  pur- 
pose of  withdrawing  the  tube.  It  is  generally  left  in  situ  until  the 
first  change  of  dressings.  If  there  is  no  purulent  discharge  visible  in 
the  dressings  removed  from  the  third  to  the  fifth  day,  the  tubes  can  be 
safely  withdrawn.  If  the  healing  was  not  entirely  faultless,  as  seen  from 
the  presence  of  more  or  less  pus  in  the  dressings,  it  will  be  safer  to  re- 
introduce a  short  piece  of  tubing  for  the  purpose  of  keeping  patent  the 
external  end  of  the  tube-track  until  the  discharges  shall  have  become 
scanty  and  serous. 

When  a  wound  is  in  good  condition  and  no  pyogenic  or  tubercular 
infection  be  present,  the  surgeon  will  find  it  a  very  diflicult  matter  to  keep 
a  tube  in  place  for  a  long  time,  should  he  desire  to  do  so.  The  cicatrization 
of  the  deeper  parts  of  the  drainage-hole  will  irresistibly  expel  the  tube,  ot 
granulations  will  invade  the  lumen  of  the  tube  through  its  lateral  fenestrse, 
and  will  simply  fill  it  up  completely. 

The  tube  should  be  always  extracted  for  inspection  at  the  first  change 
of  dressings.  If  it  is  found  to  be  filled  up  with  a  more  or  less  solid  clot  of 
sweet  blood  or  fibrin,  the  interior  of  the  wound  can  be  assumed  to  be  in 
good  condition.  Should  the  clots  be  foul  and  semi-fluid,  the  tube  must  be 
shortened  and  replaced  after  thorough  cleansing. 

The  decalcified  bone  drainage-tubes,  devised  by  Neuber,  have  been 
abandoned  by  the  author  on  account  of  their  many  inconveniences  not 
overbalanced  by  the  advantage  of  their  absorbability. 

Glass  drainage-tubes,  provided  with  a  number  of  lateral  holes,  are  used 
extensively  in  abdominal  surgery.  By  placing  within  their  hollow  a  wick 
of  iodoform  gauze,  tubular  and  capillary  drainage  can  be  combined  to  great 
advantage. 

It  may  be  said,  on  the  whole,  that  rubber  tubing  has  so  far  not  been 
supplanted  by  anything  better  for  jaurposes  of  ordinary  wound  drainage. 

B.    Applicatiox   of  Aseptic   Method  to   Diverse   Orgaxs  axd 

PiEGIOXS. 
L   LIGATURES   OF   ARTERIES   IN   THEIR   CONTINUITY. 

With  due  observance  of  the  rules  of  surgical  dissection  and  of  the  laud- 
marks  pointed  out  by  anatomy,  the  exposure  and  deligation  of  the  larger 
arteries  will  present  no  serious  difficulty. 

The  treatment  of  the  vascular  sheath  deserves  some  S2)ecial  remark. 

Free  incision  of  the  sheath  will  be  found  to  facilitate  very  much  the 
isolation  of  the  vessel.  No  fear  need  be  entertained  of  causing  thereby 
necrosis  or  sujipuration  in  an  aseptic  wound. 

The  sheath  should  be  grasped  and  raised  with  a  pair  of  mouse-tooth 
forceps,  and  the  cone  thus  formed  should  be  incised  with  the  knife  held 
horizontally.  The  incision  can  be  extended  to  half  an  inch  in  length.  (See 
Fig.  33.) 


SPECIAL  APPLICATION   OF   THE  ASEPTIC   METHOD.  49 

Isolation  of  the  vessel  is  best  accomplished  by  gently  insinnatino-  into 
the  slit  the  point  of  a  bent  silver  probe,  while  the  edge  of  the  cut  is  held  up 


Fig.  33. — Incising  the  vascular  sheath.     (Esmarch.) 


by  the  mouse-tooth  forceps.  As  soon  as  the  j^oint  of  the  probe  emerges  on 
the  opposite  side  of  the  artery,  it  is  followed  up  by  an  aneurism-needle 
armed  with  a  catgut  thread,  which  is  tied  in  a  square  knot. 

Encircling  a  vessel  with  an  aneurism-needle  having  a  sharp  or  even  a  too 
slender  point  may  lead  to  j^iercing  of  the  artery  wall  by  the  instrument. 

Case  I. — Carl  Tompert,  carpenter,  aged  forty,  noticed  in  October,  1881,  a  pulsating 
swelling  on  the  left  side  of  his  neck.  By  February,  1882,  it  had  attained  the  size  of  a 
goose's  egg.  March  2d. — Ligature  of  left  common  carotid  between  the  heads  of  the 
sterno-raastoid  muscle  at  the  German  Hospital.  In  passing  aneurism-needle  under  the 
artery  without  the  exertion  of  unusual  force,  suddenly  a  jet  of  arterial  blood  was  seen  to 
spurt  up  from  the  wound.  Traction  on  the  aneurism-needle  controlled  the  hsemorrhage, 
A  catgut  ligature  was  passed  around  the  artei'y  above  and  another  below  the  aneurism- 
needle,  and  both  were  tied.  The  artery  was  divided  between  the  ligatures,  and  then 
it  was  ascertained  that  the  aneurism-needle  had  made  a  longitudinal  slit  into  the 
artery  wall.  No  drainage-tube  was  used,  and  the  wound  was  closed  by  a  few  catgut 
sutures.  Pulsation  of  tlie  tumor  had  ceased,  and  subsequently  it  shrunk  away  to  a 
stout  cord-like  structure.  The  wound  healed  by  the  first  intention  and  no  fever 
occurred,  but  the  first  two  days  following  the  operation  very  profuse  general  per- 
spiration was  observed.     Patient  was  discharged  cured,  March  20. 

In  this  and  the  subsequent  cases,  as  well  as  in  all  other  operations  done 
hy  the  author  since  1877,  catgut  was  used  exclusively  as  ligaturing  material 
with  the  greatest  satisfaction.  Only  one  case  of  suppuration  occurred  in 
which  the  infection  could  be  traced  to  the  use  of  impure  catgut  (page  8). 
Secondary  haemorrhage  by  slipping  of  the  ligature  was  observed  twice 
(page  72).  Even  in  suppurating  wounds,  catgut  has  been  found  to  be  a 
safe  ligaturing  material.  It  is  in  every  way  preferable  to  silk,  and  in  no 
case  was  its  use  ever  regretted.  Those  who  have  been  accustomed  to  tie 
vessels  with  silk,  usually  employ  too  much  force  in  tightening  catgut  liga- 
tures. They  overtax  the  strength  of  the  animal  thread,  and  to  their  great 
annoyance  constantly  break  it.  A  small  amount  of  traction  is  sufficient  to 
safely  tighten  the  knot,  as  it  is  not  necessary  nor  desirable  to  sever  the  inner 


50  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

coat  of  the  artery.  The  many  cuts,  so  common  on  the  ulnar  side  of 
surgeons'  fingers  at  the  time,  when  silk  was  generally  employed  for  tying 
vessels,  are  very  rarely  seen  nowadays.  To  j^reserve  its  strength,  catgut 
should  never  be  immersed  in  any  kind  of  a  watery  solution,  as  it  is  apt 
to  become  swollen  and  soft  when  brought  in  contact  with  water.  The  dish 
holding  the  ligatures  at  an  operation  should  be  dry,  or  should  contain 
absolute  alcohol. 

In  all  the  cases  here  reported,  no  drainage-tube  was  used,  reliance  being 
placed  on  natural  drainage.  The  catgut  sutures  employed  were  few  and  loose, 
and  permitted  a  free  escape  of  the  oozing  during  the  first  twenty-four  hours. 

Primary  union  of  the  wounds  occurred  in  every  case. 

Case  IT. — Herrmann  Stinze,  fishmonger,  aged  forty-six,  admitted  to  German  Hos- 
pital January  3,  1880,  with  aneurism  of  the  femoral  artery,  situated  just  underneath 
Poupart's  ligament,  displacing  it  forward  and  upward.  Syphilis  admitted.  Causation, 
severe  effort  at  rowing  fifteen  months  before  admission  to  hospital.  Direct  compression 
of  swelling  was  unsuccessfully  employed  for  eighty  hours.  Jan.  17th. — Deligation  of 
external  iliac  artery.  No  drainage-tube.  Catgut  suture.  Prompt  establishment  of 
collateral  circulation.  Primary  union.  Discharged  cured  February  28th.  Patient 
examined  March  28th,  when  at  the  site  of  the  aneurism  a  cord  of  the  size  of  the  middle 
finger  could  be  felt. 

Case  III. — Henry  Greenwald,  clerk,  aged  fifteen.  End  of  June,  1882,  sustained 
stab-wound  of  left  palm,  followed  by  copious  hsemorrhage,  which  ceased  spontaneously. 
Development  of  pulsating  swelling  of  palm,  which,  by  the  direction  of  the  family 
physician,  was  kept  tightly  compressed  with  a  leaden  bullet.  Aug.  17th. — In  the 
Catskills  severe  arterial  haemorrhage  from  pressure-sore  over  swelhng,  when  bullet  was 
removed  and  another  compressory  bandage  was  applied.  Aug.  ^O^A.— Renewed  hjemor- 
rhage.  Esmarch's  band  being  applied,  the  clot  w^as  turned  out  of  the  open  sore,  the 
sac  of  the  size  of  a  hazel-nut  was  split  and  excised,  and  both  afferent  vessels  were  tied. 
Suture.     Primary  union  followed. 

Case  IV. — August  M.,  agent,  aged  forty-one,  suffering  from  progressed  ataxia, 
cut  his  ulnar  artery  August  20,  1881,  in  a  suicidal  attempt.  Hfemorrhage  was  arrested 
by  pressure  made  by  a  physician  who  attended  to  the  patient  immediately  after  the 
attempt.  Aug.  23d. — Secondary  liseTnorrhage.  Esmarcli's  band  being  applied,  the 
wound  was  dihited,  and,  the  partially  cut  artery  being  exposed,  was  doubly  tied  and  cut 
through  between.     Suture.     Primary  union. 

Case  V. — Alexander  Goerlitz,  engraver,  aged  tliirty-four.  Had  chancre  eleven 
years  ago,  and  had  been  in  the  habit  of  folding  his  legs  while  at  work.  June,  1883. — 
Noticed  pulsating  swelling  in  right  popliteal  space.  8ej)t.  15th. — Circumference  of 
left  knee,  thirteen,  of  right  knee,  sixteen  and  a  quarter  inches.  Knee  semi-flexed. 
Skin  over  aneurism  dusky  and  hot.  Esmarch's  constrictor  applied  above  and  below 
swelling  for  an  hour  under  ether  without  success,  circumference  increasing  to  seven- 
teen and  a  quarter  inches.  Sept.  19th. — Ligature  of  right  superficial  femoral  artery  in 
middle  of  thigh.  Sept.  21st. — Swelling  hard,  non-pulsating.  Paralysis  of  dorsal 
flexors  of  foot  and  of  extensors  of  toes.  No  necroses.  Primary  union.  May  17,  I884. 
— Knee  can  be  fully  extended,  paralysis  disappeared,  muscles  of  leg  have  regained  their 
normal  bulk,  tumor  shrunken  to  a  small,  hard  mass. 

Case  VI. — August  Bente,  cigar-maker,  aged  fifty-one.  No  syphilis.  In  the  sum- 
mer of  1883  felt  neuralgic  pains  in  right  arm,  followed  by  wasting  of  the  brachial 
muscles,  cyanosis,  formication,  and  hyperidrosis  of  the  extremity.  In  December 
severe  dyspnoea  supervened,  and  a  pulsatile  swelling  under  the  right  sterno-clavicular 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.  51 

junction  and  in  the  lower  cervical  triangle  was  made  out  by  Dr.  John  Schmidt,  who 
directed  tlie  patient  to  the  author,  then  on  duty  at  the  German  Hospital.  Aneurism 
of  the  innominate  and  subclavian  arteries  at  their  junction  was  diagnosticated,  and 
simultaneous  ligature  of  the  right  common  carotid  and  the  axillary  arteries  was  per- 
formed January  16,  1884.  The  latter  vessel  was  tied  in  Mohrenheim's  triangle,  just 
below  the  outer  third  of  the  clavicle.  No  drainage-tubes ;  suture.  Immediately  after 
the  operation  the  pulsation  of  the  swelling  became  more  pronounced,  and  for  the  next 
four  weeks  the  shooting  pains  in  the  arm  were  much  complained  of.  Both  wounds 
healed  by  primary  intention.  Toward  the  end  of  February  decrease  of  the  swelling 
and  moderation  of  the  subjective  symptoms  became  manifest.  In  March  and  April 
thirty  hypodermic  injections  of  Bonjean's  ergotine  were  made  in  the  abdominal  region, 
•and  seemed  to  hasten  the  shrinking  of  the  tumor.  By  May,  the  cyanosis,  sweating, 
■glossy  skin,  and  formication,  as  well  as  the  neuralgic  symptoms,  had  very  much  abated, 
and  the*  patient  had  gained  ten  pounds  of  flesh.  Under  massage,  the  application  of 
faradism,  and  active  exercise,  the  atrophy  of  the  muscles  had  also  materially  improved, 
and  in  June  the  patient  could  resume  his  occupation.  Nov.  11,  1884. — Patient  was 
presented  to  the  Surgical  Society.  Pulsation  had  almost  entirely  disappeared,  and 
what  there  was  of  it  seemed  to  be  transmitted.  Bruit  was  not  noticeable.  A 
well-perceptible  fullness  and  resistance  could  still  be  made  out  in  the  right  supra- 
clavicular fossa.  Occasionally  short  and  mild  attacks  of  shooting  pains  were  felt 
in  the  arm  and  nape  of  the  neck.  A  claw-like  deformity  of  the  nails  of  the  right  hand 
remained  unaltered.  In  August,  pulsation  and  other  signs  of  relapse  were  noted, 
with  increasing  pain,  radiating  toward  the  occiput.  Renewed  injections  of  ergot  were 
without  avail.  In  October,  during  the  author's  absence  from  town,  Dr.  Adler  incised 
an  abscess  pointing  in  the  supraclavicular  space,  and  a  few  days  later  performed  tra- 
•cheotomy  for  threatening  asphyxia.  A  sharp  pneumonia  followed,  from  which  the 
patient  recovered  only  to  succumb  in  November  to  sudden  suffocation.  No  autopsy 
was  permitted. 

Case  YII. — John  H.  Nittinger,  grocer,  aged  forty-five.  No  syphilis;  had  had 
articular  rheumatism  seven  years  before.  Pulsating  swelling  of  left  popliteal  space  of 
the  size  of  a  man's  fist.  Leg  had  been  cedematous  for  three  months;  marked  emacia- 
tion. Jan.  20,  1885. — Ligature  of  left  femoral  artery  in  Scarpa's  triangle.  Primary 
union  of  wound.  Recovery  retarded  by  circumscribed  necrosis  of  integument  over 
tuberosity  of  calcaneum  (due  to  pressure?).     Discharged  cured,  March  30,  1885. 

Case  VIII. — Emmanuel  Luecke  (see  history  on  page  186). 

Case  IX.— Robert  Klaile,  school-boy,  aged  fourteen.  Congenital  arterio-phlebec- 
tasiaof  anterior  part  of  left  foot;  pulsating,  dusky  swelling,  of  doughy  feel,  of  dorsum 
and  planta  pedis.  Along  the  course  of  saphenous  nerve  were  seen  a  series  of  flat,  hard, 
■dark-blue,  rough  nodes,  some  of  them  as  large  as  a  silver  quarter,  their  size  tapering 
off  toward  ankle.  Two  of  them  were  ulcerated  and  covered  by  a  dry  scab.  Left  foot 
on  the  whole  larger  than  its  mate.  Pulsation  of  femoral  arteries  abnormally  strong. 
Heart  hypertrophied.  Ablation  of  diseased  parts  was  declined.  July  7,  1885. — Liga- 
ture of  superficial  femoral  artery.  Short  stoppage,  and  return  of  pulsation.  Imme- 
diate ligature  of  external  iliac  of  same  side.  Wounds  sutured ;  no  drainage.  Primary 
union.  Necrosis  of  terminal  phalanges  of  first  and  second  toes,  of  the  integument  of  the 
•external  side  of  leg,  and  of  peroneus  longus  muscle.  Scanty  aseptic  suppuration,  and 
very  slow  detachment  under  antiseptic  dressing.  Tardy  cure.  The  cicatrices  on  the 
toes  became  ulcerated  in  the  winter,  and  the  pulsation  of  the  tumor,  which  had  not 
diminished  in  size,  had  returned.  Jan.  29,  1886. — PirogofE's  amputation.  Unusual 
number  of  ligatures  required  on  account  of  many  abnormally  large  arteries.  Cap  of 
•calcaneum  was  fixed  to  tibia  by  steel  nail  driven  through  from  below.     Catgut  suture. 


52 


RULES  OF  ASEPTIC  AND   ANTISEPTIC  SURGERY. 


Drainage  through  oonnter-iuoision  alongside  of  tendo  Achillis.  No  fever  followed. 
First  change  of  dressings  was  done  February  10th.  Primary  union  was  observed 
throughout,  except  where  a  narrow  strip  of  the  integument  had  necrosed  along  the 
anterior  part  of  the  incision.  Dry  dressing.  February  24th. — All  firmly  healed. 
Patient  walks  well  without  support. 

Case  X. — Louis  Wiersch,  aged  forty-two.  diffuse  cirsoid  aneurism  of  right  tem- 
poral region.  July  2JI,,  1888. — Deligation  of  external  carotid  and  of  four  large  col- 
lateral vessels.  Primary  union.  Marked  diminution  of  pulsation.  Discharged  im- 
proved, August  4th. 

Case  XI. — Carlo  Somma,  laborer,  aged  fifty-three,  fusiform  aneurism  of  right 
axillary  artery.  March  2,  1888. — Ligature  of  subclavian  artery,  third  division. 
Immediate  cessation  of  pulsation,  and  subsequent  rapid  shrinkage  of  tumor.  Dis- 
charged cured,  March  16th. 


n.    EXTIRPATION   OF   TUMORS. 

In   removing  tumors,   three  requirements  have  to    be  commonly  held 
m  view  : 

Firstly,  the  avoidance  of  septic  infection  from  witliout  or  from  within. 

Secondly,  the  complete  removal  of  the  neoplasm. 

Tliirdly,  its  safe  removal. 

How  to  avoid  infection  from  without  was  seen  in  previous  chapters  of 
this  book.     By  infection  from  within,  two  kinds  of  infection  are  meant. 

One  is  the  contamination  by  septic  contents  of  the  tumor  that  may  escape 
into  the  wound  through  an  accidental  cut  or  a  laceration  of  the  tumor, 
caused  by  rough  handling  or 
the  careless  use  of  sharp  re- 
tractors, as,  for  instance,  in  ex- 
tirpating suppurating  glands. 

Case. — Sarah  Barn,  servant, 
aged  sixteen;  old  Pott's  disease 
of  the  cervical  vertebrae :  large 
glandular  swelling  of  right  sub- 
maxillary region,  with  several  si- 
nuses leading  down  toward  the 
spine.  It  was  pretty  certain  that 
no  serious  degree  of  the  affection 
of  the  vertebrae  could  be  present, 
as  the  function  of  the  cervical 
spine  was  nearly  normal.  Xovem- 
ier  4i  1886. — Flap  incision  and 
exsection  of  the  large  mass  of 
tubercular  glands  at  Mount  Sinai 
Hospital.  Though  the  utmost  care 
was  exercised  in  not  grasping  the 

glands  with  sharp-pointed  instruments,  one  of  them  broke  down,  and  poured  out 
its  contents  into  the  large  wound.  As  subsequent  events  demonstrated,  seemingly 
thorough  irrigation  with  a  strong  solution  of  corrosive  sublimate  did  not  disinfect  all 


Fig.  34. — Gluteal  tumor  betore  extirpation. 


SPECIAL  APPLICATION  OF  THE  ASEPTIC   METHOD. 


53 


Fio.  35. — Gluteal  dresslnor. 


the  parts  of  the  wound.     The  dissection  mainly  extended  into  the  intermuscular  space 

namely,  the  slit  between  the  scaleni  and  the  posterior  border  of  the  sterno-mastoid. 

After  the  removal  of  the  mass,  the 
finger  was  easily  inserted  into  a 
track  leading  toward  the  second 
vertebra,  the  anterior  surface  of 
which  was  found  rough  and  bare 
of  periosteum.  It  was  thoroughly 
scraped  and  irrigated  (the  instru- 
ment could  be  felt  in  situ  from  the 
oral  cavity) ;  the  outer  wound  was 
drained,  sutured,  and  dressed.  Nov. 
5th. — High  fever,  with  much  de- 
jection. Skin  below  ear  red,  pain- 
ful, and  swollen.  The  flap  was  re- 
opened, and  a  small  abscess  was 
detected  just  under  the  base  of  the 
flap,  where  probably  irrigation  had  been  insufiicient.  Open  treatment.  Temperature 
fell  oflE  to  normal  at  once.     The  patient  was  discharged  cured  December  1st. 

The  other  kind  of  infection  is  the  dissemination  through  the  lymphatics 
of  cancerous  or  sarcomatous  cell-elements  into  the  body  caused  by  pressure 
due  to  rough  manipulation  of  the  tumor. 

Note. — It  is  a  well-known  fact  that,  in  some  cases  of  malignant  tumor  of  slow  growth,  after 
operation,  a  large  number  of  secondary  nodes  will  spring  up  and  develop  with  great  rapidity  in 
the  neighborhood  of  the  cicatrix.  Two  causes,  either  singly  or  combined,  may  be  at  the  bottom 
of  this  phenomenon. 

Either  the  operation  was  incomplete — that  is,  the  surgeon's  dissection  hugged  the  tumor 
too  closely,  leaving  behind  a  number  of  outstanding  microscopical  foci, — or  the  forcible  manipu- 
lations of  the  tumor  during  the  operation  have  disseminated  along  the  lymphatics  and  veins 
embryonal  cell-elements  of  malignant  character  into  the  vicinity  of  the  wound  or  throughout  the 
body.  This  is  commonly  called  "change  of  the  character  of  a  malignant  neoplasm,  due  to 
mechanical  irritation." 

Undoubtedly  there  are  many  cases  where  an  incomplete  operation  leads  to  wide  dissemina- 
tion of  the  elements  of  the  neoplasm.  In  these  cases  relapse  in  the  unhealed  wound  or  in  the 
fresh  cicatrix  is  observed,  together  with  the  simultaneous  appearance  of  regional  and  more  dis- 
tant nodes  of  new  formation. 

Thus  an  incomplete  or  rough  operation  may,  by  generalization  of  the  disease,  hasten  instead 
of  retarding  the  patient's  death. 

Seasonable  hope  of  the  complete  removal  of  a  malignant  new-growth  is 
the  main  justification  for  operative  interference.  There  is,  to  be  sure,  a 
considerable  class  of  cases  where  complete  removal  is  from  the  outset  out 
of  the  question.  Great  discomfort  from  putrescence  of  a  sloughing  tumor 
or  frequent  hsemorrhages  do  sometimes  indicate  partial  removal.  But, 
wherever  possible,  complete  removal  is  to  be  aimed  at  by  all  permissible 
means,  as  the  non-return  of  the  disease  depends  solely  upon  the  fulfillment 
of  this  condition. 

Our  third  object  must  be  to  remove  the  tumor  with  the  least  possible 
amount  of  immediate  danger  to  the  patient's  life.  Careful  and  deliberate 
dissection,  guided  by  anatomical  knowledge,  limiting  of  the  haemorrhage 


54 


RULES  OF  ASEPTIC  AND   ANTISEPTIC  SURGERY. 


to  a  minimum,  and  avoidance  of  accidental  injury  to  important  organs,  is 
meant  hereby. 

The  most  important  condition  to  be  fulfilled  in  eschewing  these  dangers 
is  an  adequate  incision. 

A  too  large  incision  never  can  do  any  harm,  its  worst  consequence  being 
the  necessity  for  a  few  more  suture-points.  An  insufficient  incision,  on  the 
other  hand,  may  be  the  source  of  great  danger  to  the  patient,  and  of  much 
embarrassment  to  the  surgeon. 

When  the  incision  is  ample,  the  new-growth  and  its  connections  can  be 
readily  exposed  without  the  use  of  much  traction  from  sharp  or  blunt  hooks, 
and  forcible  grasping  and  dragging  to  and  fro  of  the  tumor  itself  will  be 
unnecessary.  Most  of  the  vessels  that  are  to  be  divided  will  be  noticed,  and 
can  be  cut  between  two  artery  forceps  without  loss  of  blood.  Accidentally 
injured  vessels  can  be  easily  secured  and  tied  off. 

The  wretched  expedient  of  digging  a  malignant  tumor  out  of  its  capsule, 
and  leaving  behind  the  latter,  should  never  be  resorted  to,  as  a  speedy 
relapse  is  certain  to  follow. 

Dissection  should  be  done  altogether  with  the  knife,  and  exclusively 
in  healthy  tissues.  Blunt  methods  of  preparation  are  not  to  be  used  at 
all,  since  they  are  unnecessary,  and  involve  a  certain  amount  of  rough 
force. 

In  removing  infiltrating  or  ill-defined  malignant  new-growths,  the  sur- 
geon's knife  should  give  the  tu- 
mor a  wide  berth,  and  all  cosmetic 
or  functional  considerations  not 
involving  present  danger  should 
be  disregarded,  the  first  object 
being  the  complete  eradication  of 
the  disease. 

Note. — In  extirpating  malignant  new- 
growths,  which  are  known  to  cause  an  in- 
fection of  the  contiguous  lymphatic  glands 
at  an  early  stage  of  their  development,  the 
rule  of  removing  these  involved  lymphatic 
glands  together  with  the  fat  wherein  they 
are  imbedded,  should  never  be  disregarded 
without  a  very  cogent  reason  of  expe- 
diency.    The  absence  of  a  gross  lymphatic 

tumor  is  no  evidence  of  the  freedom  from  infection  of  the  pertinent  lymphatic  glands.  The 
additional  traumatism  caused  by  this  complementary  step  is  richly  repaid  by  the  vast  improve- 
ment of  the  patient's  chances  against  a  speedy  relapse. 

In  an  ample  wound  the  tumor  can  be  handled  with  the  necessary 
gentleness,  and  the  main  attack  can  be  directed  upon  its  adhesions  to  the 
surrounding  tissues.  With  rare  exceptions,  sharp  retractors  are  never  to 
be  plunged  into  the  tumor.  They  should  be  used  on  the  edges  of  the 
wound  for  dilatation,  the  tumor  itself  being  held  by  hand  throughout. 

The   softer   the   mass   of   the    tnmor,   the   greater  care    must  be  exer- 


Fia.  3(5. — Axillary  tumur  before  extirpation. 


SPECIAL   APPLICATION   OF   THE   ASEPTIC   METHOD. 


f)0 


Fig.  -37. — Axillary  wound,  imited,  after  extirpation  of  tumor. 


cised  not  to  injure  it.  Cysts  especially  require  very  tender  treatment. 
Lipomata  and  fibromata  will  stand  a  good  deal  of  rough  handling  with- 
out harm. 

XoTE. — In  former  days  lipomata  used  to  have  a  bad  reputation.     It  was  said  that  their 

extirpation  was  often  followed  by  erysipelas  and  phlegmon.     One  of  the  first  operations  ever 

witnessed  by  the  author  was  done  upon  a  healthy  young  man  in  1868  in  Prof.  D.'s  clinic,  at 

Vienna,  for  a  lipoma  of  the  shoulder.     It  caused  the  patient's  death 

from  septictemia.     This  peculiarity,  noted  by  surgeons  in  times  gone 

by,  was  undoubtedly  due  to 
the  readiness  with  which  a 
phlegmonous  process  will 
spread  in  loose  and  ill-nour- 
ished adipose  tissue.  Of 
course,  the  infection  always 
came  from  the  hands  and 
apparatus  of  the  surgeons 
themselves. 


Where  should  dis- 
section first  he  direct- 
ed to,  is  a  question, 
that  puzzles  every  be- 
ginner, and  it  is  not  in- 
different from  which 
side  we  approach  a 
tumor.  Surgery  owes  to  Langenbeck  a  clear  exposition  of  the  principle 
which  should  guide  us  in  this  matter. 

In  excising  tumors  holding  close  relations  to  large  vessels,  as,  for  instance, 
those  in  the  neck,  axilla,  and  in  Scarpa's  triangle,  the  greatest  safety  lies  in 
first  exposing  these  vessels  alove  and  below  the  tumor,  so  as  to  have  full  con- 
trol  of  them  during  the  subsequent  steps  of  the  operation.  This  precaution 
offers  great  security  against  injury  of  those  vessels,  and  at  the  same  time 

reduces  to  a  minimum 
the  otherwise  formida- 
ble dangers  of  such  ac- 
cidental injury,  should 
it  occur.  If  it  become 
evident  that  the  tu- 
mor has  involved  the 
walls  of  the  adjacent 
large  vessels,  a  ligature 
above,  another  below 
the  growth,  will  per- 
mit of  a  safe  and  com- 
plete exsection  in  one 
mass  of  the  tumor  and 
the  diseased  parts  of 
the  vessel. 


Fig.  38. — Flap  incision  for  removal  of  tumor  of  neck, 
di'ained  and  sutured. 


Wound 


56 


EULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


Note. — It  is  the  common  tendency  of  young  surgeons  to  carry  too  far  the  dissection  of 
a  vessel  adhering  to  a  tumor.     This  is  actuated  by  the  desire  of  preserving  the  integrity  of  the 

vessel  in  question,  and  by  the  natural  disinclination 
of  complicating  the  operation  by  double  ligature, 
which  again  involves  extra  dissection.  The  con- 
sequence of  this 
tendency  may  be 
twofold  :  cither 
portions  of  the 
tumor  adhering 
to  the  vessel  wall 
are  left  behind  to 
cause  speedy  re- 
lapse, or  the  vein 
is  cut  or  torn. 


Fig.  39. — Uressint;  for  neck  wounds. 


Fig.  40. — Dressing  of  neck  wound  completed 
by  rubber-tissue  bib  and  arm-sling. 


Whenever  the  surgeon  has  succeeded  in  formmg  a  pedicle  to  a  tumor  situ- 
ated in  the  vicinity  of  large  vessels,  cuttinfj  of  such  a  pedicle  without  first 
tying  it  off  is  a  very  risky  step.  Traction  upon  the  tumor  will  obliterate 
any  vessels  included  in  the  pedicle,  and,  when  cut,  the  innocent-looking 
mass,  closely  resembling  ordinary  connective  tissue,  may  open  up  into  unex- 
pected and  overwhelming  springs  of  welling  blood.  The  stump  will  at  once 
retract,  and  finding  and  securing  the  retracted  vessel  in  an  inexhaustible 
pool  of  blood  is  a  terribly  difficult,  sometimes  impossible,  thing.  Should  it 
be  an  artery,  the  tips  of  two  or  three  fingers  must  be  thrust  at  once  into  the 
place  from  which  the  hsemorrhage  is  issuing.  The  blood  must  be  mopped 
up  by  rapid  sponging,  to  enable  the  surgeon  to  find  the  vessel,  in  order  to 
secure  it  with  an  artery  forceps,  or  to  surround  it  by  a  suture  passed  through 
the  adjacent  tissues.  His  mettle  will  be  put  to  the  severest  test,  and  it 
will  be  a  lucky  day  if  his  patient  do  not  succumb  on  the  table. 

In  trying  to  secure  the  stump  of  a  large  vein  accidentally  cut  across,  the 
wide  extent  of  its  circumference  will  offer  much  difficulty,  as  an  ordinary 
artery  forceps  is  too  small  to  take  in  the  entire  lumen  of  the  vessel.  One 
or  more  great  leaks  will  remain,  even  if  the  vessel  be  fortunately  grasped  by 
one  forceps.     Two,  three,  or  more  additional  instruments  have  to  be  brought 


SPECIAL  APPLICATION   OF  THE  ASEPTIC   METHOD. 


0/ 


into  requisition  till  the  end  is  accomplished.  The  haste,  natural  and  almost 
unavoidable  on  such  occasions,  will  easily  lead  to  further  tearing  of  the  soft 
walls  of  the  vessel,  and,  finally,  salvation  will  have  to  be  sought  in  plugging 
with  iodoform  gauze.     Here  prevention  is  much  easier  than  cure. 

Lateral  tearing  or  slitti7ig  of  a  large  vein  is  another  accident  to  which 
disregard  of  Langen beck's  rule  may  lead.  There  are  two  ways  out  of  this 
contingency.  One  is  to  expose  and  deligate  the  vein 
above  and  below  the  laceration,  while  the  fingers  of  au 
assistant  compress  the  injured  part  of  the  vessel.  The 
other  one  is  the  application  of  a  lateral  ligature  or  a  con- 
tinuous suture  of  fine  catgut  occluding  the  rent. 

Both  of  these  latter  methods,  however,  are  difficult 
and  not  very  reliable,  though  they  have  succeeded  in  the 
hands  of  several  surgeons,  including  the  author's.* 

They  were  bred  of  the  fear  of  tying  large  veins,  for- 
merly so  prevalent  on  account  of  the  dangers  of  phlebitis 
and,  in  the  extremities,  of  gangrene.  In  cases  where  a 
large  portion  of  the  vein  wall  is  lost  by  sloughing  or  cut- 
ting, and  the  resulting  aperture  is  very  large,  lateral  liga- 
ture and  suture  are  impossible.  "Whenever  feasible,  a 
double  ligature  should  be  applied,  whether  it  concerns  the  deep  jugular  or 
axillary  and  femoral  veins.  Langenbeck's  advice  to  tie  the  accompanying 
large  artery  has  been  much  impugned  lately,  as  it  was  found  that  gangrene 
of  the  extremity  followed  its  adoption.  On  the  other  hand,  a  growing  num- 
ber of  cases  are  on  record,  where  deligation  of  the  femoral  or  axillary  vein 
led  only  to  temporary  disturbance  of  no  great  import. 

Case. — Henry  Rickriegel,  carpenter,  aged  twenty-three,  admitted  to  German  Hos- 
pital, March  2.  1887.     Two  days  later  the  house-surgeon  extirpated  a  mass  of    sup- 
purating glands  from  Scarpa's  triangle  of  the  right  side.    The 
saphenous  vein,  which  passed  into  the  tumor  from  belo\\', 
was  tied  and  cut  across.     Likewise  were  treated  a  number 
of  larger  veins  entering  the  tumor  from  above.     The  femoral 
vessels  were  not  exposed,  but  the 
pulsation  of  the  artery  could  be 
distinctly  felt,  and  it  was  care- 
fully held   aside.     Finally,   the 


Fig.  41. — Lateral  lig- 
ature and  continu- 
ous suture  of  in- 
jured vein. 


JTiG.  42. — Periosteal  myxosarcoma  of  thigh  before  removal. 

*  In  a  case  of  exsection  of  lymphomata  of  the  neck,  done  in  1880  in  the  German  Hospital, 
where  the  deep  jugular  was  injured.     The  patient  recovered. 


58 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


mass  was  freed  all  around,  until  a  stout  pedicle  was  formed,  which  was  seen  entering 
the  oval  foramen  of  the  fascia  lata.  This  pedicle  was  tied  with  catgut  and  was  cut 
through.  In  the  mean  time  the  patient  had  be- 
come semi-conscious  and  began  to  struggle,  where- 
upon, suddenly,  an  enormous  jet  of  venous  blood 
was  seen  to  well  uj)  from  the  bottom  of  the  wound. 
The  operator  plunged  his  fist  into  the  pool  of 
blood,  and  thus  succeeded  in  checking  the  hsemor- 
je    until     Dr. 


Fig.  43. — United   wouud    alter  ruiiiuval  ol  iiiyxo.'^arcoiua  of  thigh. 


Bachmann,  the 
chief  of  the  house- 
staff,  appeared, 
who  luckily  suc- 
ceeded, with  the 
aid  of  Thiersch's 
spindles,  in  pass- 
ing two  ligatures, 
one  below,  the 
other  above  the 
bleeding  point,  ef- 
fectually stopping 
tlie  formidable 
loss  of  blood.  Im- 
mediately,     deep 

cyanosis  and  oedema  of  the  lower  extremity  developed,  and  the  author,  who  saw  the 
patient  directly  after  the  operation,  ordered  elevation  of  the  limb,  which  was  brought 
about  by  its  vertical  suspension  in  a  wire  cradle.  March  5th. — Cyanosis  disappeared, 
oedema  much  diminished.  Temperature,  101-5°.  Circulation  of  limb  good.  The 
wound  did  well,  but,  March  18tb,  temperature  rose  to  103°  Fahr.,  and  signs  of  phlebitis 
of  the  femoral  vein  in  the  middle  of  the  thigh  appeared  in  the  shape  of  a  cylindrical, 
painful,  and  hard  infiltration.  This  and  a  number  of  similar  attacks  were  subdued  by 
the  application  of  an  ice-bag.  The  persistent  oedema  was  combated  by  elastic  com- 
])ression  with  Martin's  bandage,  supplemented  later  on  by  massage.  May  15th. — The 
patient  was  discharged  cured,  very  little  of  the  oedema  being  still  noticeable. 

In  this  case,  apparently,  a  portion  of  the  trunk  of  the  femoral  vein  was 
drawn  into  the  cone  of  the  pedicle  containing  the  root  of  the  saj)henous 
vein,  and  was  excised  along  with  the  tumor. 

The  ligature  slipped  off,  and  a  wide  gap  was  opened  in  the  side  of  the 
femoral  vein  corresponding  to  the  place  of  entrance  of  the  saphena.  The 
peculiarity  of  the  walls  of  large  veins  to  yield  to  lateral  traction  is  well 
known  to  surgeons,  and  is  a  just  source  of  anxiety,  as  the  extended  vein 
becoming  empty  can  not  be  recognized. 

Double  ligature  of  the  vein  will  be  insufficient  to  check  the  hfemorrhage 
when  a  large  branch  inosculates  between  the  two  ligatures.  Such  branch 
must  be  separately  exposed  and  tied. 

Case  I. — March  ^7,  1880. — The  surgeon  in  charge  of  the  ward  for  syphilis  and  skin 
diseases  at  the  German  Hospital  excised  a  large  glandular  tumor  from  Scarpa's  tri- 
angle on  John  Te  Gempt,  aged  twenty-four.  The  operation  was  finished  without 
accident,  and,  according  to  the  then  prevailing  custom,  the  woimd  was  mopped  with 


SPECIAL   APPLICATION   OF   THE  ASEPTIC   METHOD. 


59 


44. — Dressiuff  after  removal  of  myxosarcoma  of  thigh. 


an  eight-per-cent  solution  of  chloride  of  zinc.  Ajyril  llfh. — A  large  slough  of  the 
vein  wall  was  detached,  and  fearful  haemorrhage  ensued,  which  Dr.  Loewenthal,  the 
house-surgeon,  could  not  check  completely  by  local  pressure.  When  the  author  saw 
the  patient,  he   was   nearly   exsanguinated,  though    conscious.      ISTo   pulse   could  he 

felt.  Without  anesthesia  the  femoral  vein  was 
exposed  below  the  opening  in  its  wall,  while  press- 
ure by  three  finger-tips  completely  controlled  the 
htemorrhage. 

of  the  iist  or  of  a  sponge  into  the 
wound  will  not  check  hemorrhage 
effectually  in  these  cases.  The  tips 
of  the  fingers  pressed  exactly  upon 
the  bleeding  orifice,  and  without 
much  force,  will  always  succeed  in 
controlling  the  vessel. 

As  the  vein  bled  from  above, 
too,  Poupart's  ligament  was 
cut  across,  and  the  external 
iliac  vein  was  tied.  After  this 
the  loss  of  blood  became  very  much  diminished,  but  a  considerable  vein  inosculating 
just  opposite  the  defect  in  the  wall  of  the  femoral  vessel  required  separate  exposure 
and  deligation,  whereupon  the  haemorrhage  ceased  completely.  Unfortunately,  the 
total  loss  of  blood  had  been  so  considerable  that  the  patient  survived  the  operation 
only  a  short  time,  and  died  in  collapse  from  acute  anaemia. 

In  a  similar  case  the  difficulty  caused  by  tlie  presence  of  an  inosculating 
branch,  situated  between  the  two  ligatures,  was  overcome  by  plugging. 

Case  II.  ^Ferd.  Brenner,  aged  forty-nine.  Noteviber  22,  1889. — The  removal  of  a 
very  large  relapsed  sarcoma,  located  deeply  in  Scarpa's  triangle,  was  attempted  at  Mount 
Sinai  Hospital.  The  femoral  vein  was  found  imbedded  in  the  tumor  mass.  In  essaying 
to  ascertain  whether  the  attachment  was  loose  or  more  intimate,  a  piece  of  the  vein 
wall  measuring  three  fourths  of  an  inch,  and  involving  the  entire  width  of  the  vessel, 
came  away  with  the  tumor  when  it  was  raised.  The  very  profuse  hfemorrhage  was 
promptly  checked  by  exact  finger-pressure  upon  the  aperture  m  the  vein.  Two  liga- 
tures, one  above  the  other  below  the  tumor,  were  thrown  about  the  vein,  but  hseraor- 
rhage  continuing,  it  was  concluded  that  a  large  branch,  inosculating  between  the  two 
ligatures,  probably  the  profuda  vein,  remained  unoccluded.  As  the  excision  of  the 
tumor  was  out  of  question  on  account  of  its  diffuse  character,  search  and  deligation  of 
the  inosculatory  branch  was  deemed  inexpedient.  Hence  the  entire  lumen  of  the  vein 
included  by  the  ligatures  was  tightly  packed  with  strips  of  iodoform  gauze,  the  ends  of 
which  were  brought  out  through  the  defect  in  the  vein  wall.  The  wound  was  also 
packed  and  a  compressory  bandage  applied.  Slight  cyanosis  persisted  for  a  few  hours, 
but  had  disappeared  by  the  next  day.  Packings  removed  November  26th.  No  hfemor- 
rhage.    December  25tJi. — Patient  discharged,  with  granulating  surface. 

Deligation  and  imrtial  exsection  of  the  axillary  vein  for  ingrowing  cancer 
of  the  axillary  glands  has  been  often  performed  by  various  surgeons  with  en- 
tire success,  and  can  he  undertahen  without  hesitation  whenever  unavoidable. 

Case. — Betty  Lowy,  aged  forty-two.    Ajjril  26,  1889. — Amputation  of  right  breast 
for  extensive  carcinoma.     The  axillary  glands  are  found  to  be  very  much  involved  and 
enlarged,  the  axillary  vein  passing  through  the  middle  of  the  tumor  mass.     Excision 
.  10 


60 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


of  two  inclies  of  the  axillary  vein  between  two   catgut  ligatures.     Drainage,  suture. 
No  cyanosis  or  oedeina  of  arm  followed.    Primary  union.     Discharged  cured  May  30th. 

In  deligating  the  deep  jugtdar  vein,  avoidance  of  the  pnetimogastric  nerve 
ivill  require  close  attention.  When  there  is  enough  space  to  expose  and 
liberate  tlie  vein  freely,  this  Avill  not  be  found  very  difficult.  Low  down  at 
the  root  of  the  neck  however,  the  decision  of  the  question  whether  the 
ligature  encompasses  the  nerve  or  not  may  occasionally  be  impossible. 

Case. — Mrs.  Catharine  Plunkett,  aged  sixty-four.  Extirpation  of  recurrent  lympho- 
sarcoma of  neck,  December  22,  1886,  at  Mt.  Sinai  Hospital.  A  tumor  of  the  size  of 
a  hen's  egg  was  located  low  down  in  the  supra-clavicular  fossa.  Though  it  was  freely 
movable,  its  close  relation  to  tlie  large  cervical  vessels  was  anticipated.  A  flap  incis- 
ion and  careful  dissection  laid  bare  the  Jugular  vein  above  and  below  the  tumor,  when 
it  became  evident  that  it  would  be  imj'ossible  to  remove  it  without  excising  a  correspond- 
ing portion  of  the  vein.  The  lower  ligature  had  to  be  applied  somewhat  behind  the 
sterno-clavicular  rim,  and  on  account  of  the  lack  of  space  this  was  very  difficult.  Isola- 
tion of  the  vein  had  to  be  done  with  the  greatest  caution  to  avoid  its  injury.  Finally 
a  silver  probe  wormed  its  way  around  the  vein,  and  the  question  arose.  Was  or  was 
not  the  pneumogastric  nerve  included  in  the  ligature?  To  test  this  the  thread  was 
firmly  tied  in  a  single  knot.  No  change  whatever  of  the  respiration  or  pulse  being 
noted,  it  was  assumed  that  the  nerve  was  not  caught,  whereupon  a  double  ligature  was 
passed  through  by  means  of  the  first  thread,  and,  being  tied,  the  vein  was  cut  across. 
But  on  inspection  of  the  mass  it  became  clear  that  the  nerve  was  included  in  the  liga- 
ture and  had  been  cut  through.  The  tumor  was  easily  dissected  up  after  this  until  a 
pedicle  was  formed  containing  the  jugular  vein  from  above.  This  being  tied,  the 
tumor  was  removed.  Drainage,  suture,  and  dressings  were  applied  in  the  usual 
manner.     The  patient  recovered   without  one  untoward  symjitom.     Dec.  31st. — The 

first  dressing  was  removed,  together 

with    the    drainage-tubes.      Jan.    <?, 

1887. — She  was  discharged  cuied. 

Having  thus  gone  through 
the  entire  subject,  we  may  sum 
up  in  the  following  points  : 

To  accomplish  a  thorough  and 
at  the  same  time  safe  removal  of 
a  tumor  located  in  the  vicinity 
of  large  vessels,  an  adequate,  that  is,  very  ample,  in- 
cision is  absolutely  necessary. 

Note. — On  the  trunk  and  the  extremities,  straight  incision?,  with 
the  addition  of  a  transverse  extension,  will  be  found  most  convenient. 
Where  a  transverse  cut  is  inopportune,  considerable  gain  in  space  can 
be  effected  by  undulating  the  line  of  incision. 

In  Scarpa's  triangle,  but  especially  about  the  neck,  flap  incisions  are  the  most  convenient 


Fio.  4.'5. — Outlines  of  flap- 
incisions. 


Fig.  4G.— rt.  T-shaped 
incision,  h.  Undu- 
lating incision. 


Methodical  dissection,  guarded  by  as  many  ]ireliminary  double  ligatures 
as  necessary,  will  insure  a  steady  and  uninterrupted  progress  of  the  opera- 
tion. Loss  of  blood  will  be  minimal,  and  the  flurry  and  haste  incumbent 
upon  profuse  accidental  haemorrhage  will  not  lead,  as  it  always  does,  to  the 
disregard  of  the  rules  of  asejiticism. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.  61 

Ase]3tic  canons  are  easily  forgotten  during  frantic  efforts  to  check  dan- 
gerous haemorrhage,  although  it  is  conceded  that  avoidance  of  suppuration 
is  all  the  more  important  because  of  the  injury  to  large  vessels. 

After  thorough  irrigation  and  cleansing,  the  drainage  of  the  cavity  is 
to  be  attended  to.  It  should  he  direct — that  is,  should  reach  the  surface 
on  the  shortest  possible  route,  if  necessary  through  a  counter-incision — and 
care  must  be  taken  of  not  letting  the  square  inner  end  of  the  tube  impinge 
upon  a  large  artery.  Especially  must  this  point  be  heeded  where  the  tube 
consists  of  hard  material,  as  perforation  of  the  vessel  by  friction  against  the 
hard  edge  of  the  tube  is  possible. 

Note. — There  are  cases  on  record  where  the  innominate  was  ulcerated  through  by  friction 
pressure  of  the  margin  of  a  tracheotomy  cannula. 

The  inner  end  of  the  tube  should  be  placed  so  as  not  to  touch  the  vessels, 
the  general  direction  of  the  mesial  end  of  the  tube  being  parallel  with  them. 
To  secure  this  position  the  inner  end  of  the  tube  should  be  fastened  to  a 
suitable  part  of  muscle  or  fascia  by  a  catgut  stitch. 

Change  of  dressings  will  be  required,  according  to  the  size  of  the  tumor, 
on  from  the  third  to  the  sixth  day,  when  the  tubes  can  be  withdrawn. 

III.     AMPUTATION    OF    LIMBS. 

In  performing  a  major  amputation,  the  modern  surgeon  has  to  solve 
three  problems  : 

Tlie  first  is  to  avoid  septic  infection  of  the  amputation  wound,  or,  if 
se]3sis  of  the  limb  be  present,  to  eliminate  it. 

Tlie  second  one  is  to  limit  hsemorrhage  to  an  unavoidable  minimum. 

Tlie  third  problem  is  to  secure  a  good  stum.p. 

1.  Aseptics  and  Antiseptics  of  Amputation. — To  the  adoption  of  aseptic 
and  antiseptic  measures  must  be  ascribed  the  remarkable  reduction  of  the 
rate  of  mortality  after  major  amputations,  now  prevalent  wherever  such 
measures  are  practiced.  Formerly  one  third  of  all  cases  were  directly  lost 
mainly  through  primary  septicsemia,  or  pyaemia,  or  indirectly  by  secondary 
haemorrhage  due  to  ulcerative  destruction.  At  present,  deaths  from  acute  and 
chronic  blood-poisoning  or  secondary  haemorrhage  are  very  rare,  and  limited 
to  cases  that  come  under  the  surgeon's  knife  in  a  neglected  or  septic  state. 

The  total  mortality,  as  computed  from  nearly  1,000  unselected  hospital 
cases  of  various  surgeons,  treated  on  the  new  plan,  is  about  fifteen  per  cent. 

The  author's  personal  experience  embraces  fifty-five  cases  of  major 
.amputation,  mostly  done  in  hospital  practice.     These  were  : 

Amputations  of  the  thigh  (1  Gritti's) 30 

«  "       ipo-  9 

"  "        foot *? 

"  "       shoulder •  •      ^ 

"  "       arm ^ 

"  "      forearm 3 

Total 55 


62  RULES   OF  ASEPTIC   AND  ANTISEPTIC  SURGERY. 

Tlie  amputations  were  performed  : 

For  suppurating  compound  fracture  in 2  cases. 

"    plilegmon  of  soft  parts  in 6      " 

"    acute  and  chronic  osteomyelitis 8      " 

"    spontaneous  gangrene  (non-diabetic) 7      " 

"  "  "        (diabetic) 3      " 

"    articular  suppuration   (diabetic) 1  case. 

"  "  "  (pysemic) 1      " 

"  "  "  (uratic  i 1      " 

"  "        tuberculosis 12  cases. 

"   congenital  angio-lipoma  of  lower  extremity .  1  case. 

"    malignant  new  growths 8  cases. 

"    incurable  ulcers 5      " 

Total 55 

Of  this  number  were  cured  : 

By  primary  union 19  cases. 

"   partial  adhesion  (open  treatment  and  secondary  suture) 20      " 

With  suppuration 8      " 

Cured 47      " 

Died 8      " 

Total 55      " 

The  eight  fatal  cases  were  as  follows  : 

Case  I. — Max  Loffmann.  Amputation  of  thigh  at  Mount  Sinai  Hospital  for  second- 
ary hseraorrhage  due  to  phlegmon  of  popliteal  space  after  exsection  of  knee.  Patient 
came  on  table  collapsed,  and  died  immediately  after  ablation  (see  page  259). 

Case  II. — Gustav  Leuber,  aged  forty -nine.  March  22^  1883. — Syme's  amputation 
of  foot,  at  the  German  Hospital,  for  tuberculosis  of  tarsus.  Died  May  5,  1883,  of  gen- 
eral marasmus,  due  to  pulmonary  tuberculosis.     Wound  nearly  healed. 

Case  III. — Carl  Frank,  aged  sixty.  Senile  gangrene  of  foot  and  leg  ;  amputated  at 
the  German  Hospital.  On  account  of  the  collapsed  and  septic  condition  of  the  patient,, 
twenty  oimces  of  a  six-pro-mille  saline  solution  were  transfused  before  commencing  the 
amputation.  The  pulse  rallied,  and  transcondylic  amputation  was  done,  but  patient 
died  immediately  after  the  bone  was  sawed  off. 

Case  IV. — Louis  Bourbonus,  carpenter,  aged  twenty-nine.  Acute  progressive  gan- 
grenous phlegmon  of  hand  and  forearm.  Septicfemia  with  petechial  eruption.  Feh- 
ruary  2J!f,  1880. — Amputation  of  arm  at  the  German  Hospital.  Patient  died  two  hours 
after  ablation. 

Case  V. — Catharine  Argast,  aged  fifty-four.  Senile  gangrene  of  fore  part  of  foot. 
September  18,  1882. — Syme's  amputation  at  the  German  Hospital.  Marastic  thrombo- 
sis of  the  femoral  vein.     Died  October  23d  of  marasmus. 

Case  YI. — Beckie  Sternfeld,  married,  aged  twenty-eight.  Admitted  to  Mount 
Sinai  Hospital,  March  23,  1889,  with  puerperal  pyremia.  A  large  number  of  abscesses 
were  successively  incised,  among  them  one  involving  the  right  knee-joint.  Though  her 
case  appeared  to  be  hopeless,  amputation  of  the  right  thigh  was  done  October  28th,  to 
rid  her  of  the  pain  and  inconvenience  caused  by  the  disorganized  knee-joint.  The 
wound  was  treated  by  the  open  method,  and  was  doing  well,  though  cicatrization  waa 


SPECIAL  APPLICATION   OF   THE  ASEPTIC  METHOD.  63 

very  slow.  Xoi'emler  18th. — She  died  of  general  exhaustion  due  to  prolonged  suppura- 
tion and  chronic  nephritis. 

Case  YII. — Lazar  Schatel,  commission  merchant,  aged  forty-six.  Spontaneous 
gangrene  of  leg  due  to  endarteritis  obliterans.  Xo  diabetes.  General  atheromatosis. 
General  condition  poor.  January  i,  1889. — Amputation  of  thigh  in  lower  third. 
Femoral  artery  occluded  by  old  clot.  Open  treatment.  January  11th. — Slight  fever 
with  delirium  developed.  Marginal  necrosis  of  flaps.  January  31st. — Apoplectic 
convnlsion,  followed  by  death.  Atitojjsy :  Chronic  purulent  lepto-meningitis.  Gen- 
eral atheroma. 

Case  VIII. — Mrs.  J.  D.  Brodek,  married,  aged  sixty-five.  Senile  gangrene  of  left 
foot.  Xo  diabetes.  Amputation  of  right  thigh  had  been  performed  in  June,  1887,  for 
gangrene  of  right  foot.  October  15^  1889. — Amputation  of  left  thigh  in  lower  third. 
Occlusive  treatment.  Necrosis  of  flaps  under  septic  symptoms.  Wound  reopened. 
October  17th. — Death  from  sudden  heart  failure,  probably  due  to  septictemia. 

The  author's  total  rate  of  mortality  would  be  14*54  per  cent. 

Excluding  the  hojDeless  and  moribund  Cases  I,  III,  IV,  and  VI,  the 
death-rate  will  be  reduced  to  7*84  per  cent. 

But  one  of  the  patients  (Case  VIII)  died  of  acute  septicemia  clearly 
chargeable  to  the  operation.  Case  II  died  of  tuberculosis ;  Case  V 
(senile  gangrene),  of  thrombosis  due  to  general  marasm. 

Considering  the  large  proportion  of  amputations  of  the  thigh  (thirty), 
and  the  fact  that  ablation  was  done  twenty-nine  times  for  acute  septic  pro- 
cesses under  a  vital  indication,  during  a  more  or  less  pronounced  state  of 
general  sepsis,  the  final  results  may  be  favorably  compared  with  those 
achieved  without  antiseptics. 

In  four  cases  comjilicated  hy  grave  diabetic  symptoms  the  patients  all 
recovered,  the  proportion  of  sugar  in  the  urine  either  disappearing  or  being 
reduced  to  mere  traces  after  ablation. 

XoTE. — It  is  well  known  to  what  a  pernicious  extent  diabetic  patients  become  disposed  ta 
tissue  decay  in  the  shape  of  ulcerative  and  gangrenous  destruction,  especially  of  the  terminal 
parts  of  the  extremities.  On  tlie  other  hand,  suppurative  or  necrotic  processes  have  a  very 
marked  tendency  to  aggravate  the  symptoms  of  melituria  by  causing  a  decided  increase  of  the 
saccharine  contents  of  the  urine.  Thus,  whenever  a  diabetic  patient  becomes  the  victim  of  gan- 
grene or  a  phlegmonous  process,  his  system  will  not  only  have  to  contend  with  the  inherent  dan- 
gers of  septic  fever  and  exhaustion  from  more  or  less  extensive  suppuration,  but  his  power  of 
resistance  will  be  dangerously  sapped  by  an  aggravation  of  the  diabetes.  It  is  not  to  be  won- 
dered at,  then,  that  surgeons  will  not  be  very  eager  to  resort  in  these  cases  to  active  operative 
measures,  but  rather  will  content  themselves  with  palliatives,  practically  leaving  the  patient 
to  the  resources  of  Xature.  Most  patients  of  this  order  will  then  succumb  to  the  combined 
malignity  of  the  septic  attack  and  the  diabetes.  In  a  few  cases,  however,  the  gangrene  will 
reach  its  limits,  the  necrosed  portions  will  be  cast  oif,  and  cicatrization  will  commence.  It 
was  observed  that  whenever  this  took  place,  a  marked  reduction  of  the  quantity  of  sugar  con- 
tained in  the  urine  occurred  simultaneously  with  the  limitation  of  the  fever  and  suppuration. 
Upon  this  observation  was  based  the  plan  first  successfully  executed  by  Koenig,  to  eliminate  the 
source  of  sepsis  by  a  high  ablation  of  the  affected  member,  carrying  the  line  of  section  through 
healthy  tissues. 

The  conditions  of  success  are :  First,  to  amputate  where  the  nutrition  of  the  flaps  is  ade- 
quate to  insure  against  marginal  necrosis.  This  means  amputation  above  the  knee  in  the 
lower  extremity.  Secondly,  the  insurance  of  a  faultless  asepsis  together  with  the  open  wound 
treatment. 


64 


EULES  OF   ASEPTIC  AND  ANTISEPTIC  SURGERY. 


To  further  a  better  understanding  of  the  methods  employed  for  the 
maintenance  of  the  aseptic  condition  during  amputation,  it  will  be  neces- 
sary to  class  all  cases  requiring  ablation  in  three  groups. 

a.  Clean  Cases. — The  first  group  consists,  on  the  one  hand,  of  cases 
where  amputation  is  indicated  for  yarious  reasons,  such  as  deformities, 
tumors,  etc.,  in  which  the  skin  of  the  member  is  unbroken,  and  no  sub- 
cutaneous, acute,  or  chronic  suppuration  is  present  ;  on  the  other  hand,  of 
injuries  requiring  amputation,  that  come  under  treatment  immediately 
after  the  accident. 

These  are  called  clean  cases.  They  require  the  ordinary  aseptic  precau- 
tions, such  as  shaving,  thorough  scrubbing,  and  disinfection  of  the  field  of 
operation,  and  a  careful  protection  of  the  hands  and  instruments  of  the  sur- 
geons from  contact  with  non-disinfected  parts  of  the  patient's  body.  This 
is  best  accomplished  by  wrapping  the  whole  limb,  excepting  the  field  of 
operation,  into  a  swathing  of  disinfected  towels,  which  should  be  fixed  in 
position  by  safety-pins  or  a  few  turns  of  a  roller-bandage.     The  patient's 

feet  and  hands,  disinfec- 
tion of  which  is  difficult 
at  best,  should  never  re- 
main unnecessarily  ex- 
posed in  amputations  of 
the  upper  or  lower  ex- 
tremity. If  the  opera- 
tion is  to  be  done  near, 
or  on  the  hand  or  foot. 


^^        these  must  be,  if  time  permit, 

of  patieut  for  ampu-     :  ij^    SkJbB  '  Subjected  to  a  careful  prelim- 

tationofthish.  ^Bl.      /"^^M      1        in ary  process  of  cleansing.     It 

consists  of  a  prolonged  bath 
of  warm  soap-water,  and  sub- 
sequent packing  in  compresses  moistened  with  a  two-per-cent  carbolic  solu- 
tion, and  an  external  wrapping  of  rubber  tissue  to  prevent  evaporation. 
Large  masses  of  epidermis  will  be  soaked  off  in  this  manner,  and  can  be 
removed  by  gentle  friction  with  a  brush  or  flannel  rag  in  soap-water.  This 
process  must  be  repeated  until  the  skin  is  perfectly  clean,  and  does  not  shed 
epidermis.  The  part  to  be  operated  on  is  kept  wrapped  in  a  carbolized 
towel  until  anassthesia  is  well  under  way,  and  the  operation  is  about  to  begin. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD. 


65 


.  Esmarch's  constrictor  being  applied,  and  the  patient's  body  protected 
by  rubber  sheets,  these  and  the  parts  of  the  limb  not  needing  special  dis- 
infection are  covered  with  disinfected  moist  towels.  The  parts  of  the  assist- 
ants are  distributed,  and  every  one  takes  his  place.  Now  the  surgeon 
unwraps  the  field  of  op- 
eration, and,  having  once 
more  rubbed  it  off  with 
corrosive-sublimate  lotion, 
begins  to  operate. 

Frequent  irrigation  of 
the  wound  and  especially 
rinsing  of  the  hands  of 
operator    and     assistants 


Fig.  48. — Section  of  fennir.     Irrigator  playing 
from  the  left. 


should  not  be  neglected  until  the  dress- 
ings are  finished  and  the  patient  is  ready  for  bed.     The  other  precautionary 
detail  mentioned  in  a  previous  chapter  should  also  be  carefully  adhered  to. 

With  the  exception  of  the  saw,  most  instruments  required  for  amputa- 
tion are  easy  to  clean.  The  saw  is  a  frequent  medium  of  pyogenic  in- 
fection. 

Case. — Arnold  Bitter,  mechanic,  aged  thirty-four,  was  amputated  at  the  knee- 
joint  eighteen  years  ago  for  a  compound  fracture  of  the  leg.  On  account  of  insufficient 
covering,  a  large  adherent  cicatrix  occupied  the  under  and  posterior  side  of  the  condyles, 
which  were  constantly  ulcerated.  Re-amputation  of  the  thigh  above  the  condyles, 
January  8,  1887,  at  the  German  Hospital.  Drainage  and  suture.  Fever  developed 
on  the  second  day,  rising  to  103°  Fahr.  on  the  third,  wherefore  the  house-surgeon  re- 
moved the  dressings,  but  found  nothing  to  explain  the  pain  and  fever.  On  the  fifth 
day  the  author  inspected  the  stump,  and  found  firm  union  of  the  flaps  between  each 
other  and  to  the  sawn  surface  of  the  bone,  the  drainage-tubes  stUl  filled  with  fresh, 
sweet  clots,  but  the  extremity  of  the  stump  decidedly  club-shaped  and  oedematous,  the 
oedema  being  of  the  deep-going,  firm  variety,  characteristic  of  acute  osteomyelitis. 
The  stump  was  nowhere  painful  on  pressure,  except  at  a  point  corresponding  to  the 
upper  margin  of  the  sawn  surface  of  the  bone.  In  a  few  days  pus  began  to  exude 
from  the  drainage-tube  placed  at  tlie  time  of  the  operation  through  a  counter-incision 
into  the  quadricipital  bursa,  and  the  patient's  fever  subsided.  Feb.  9th. — The  upper 
margin  of  the  sawn  surface  was  exposed  and  a  narrow,  sharp  edge  of  necrosed  bone 
was  detected.  This  was  chiseled  away  until  healthy  bone  presented  ;  fistula  scraped, 
wound  sutured.     Primary  union  ;  patient  cured,  March  5th. 


66 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


Apparently  some  filth  had  been  detached  from  the  teeth  of  the  saw  when 
it  was  drawn  across  the  bone  the  first  few  times,  and  became  lodged  near  the 
upper  margin  of  the  bone  section,  causing  there  a  circumscribed  acute 
osteomyelitis,  ending  in  necrosis. 

XoTE.— The  proper  way  to  cleanse  a  saw-blade  is  to  scrub  it  thoroughly  for  five  minutes  in 
hot  water  with  soap  and  a  stiff  brush,  held  across  the  blade,  then  to  immerse  it  in  carbolic 
lotion  until  used.  It  is  best  to  do  this  as  the  last  thing  before  the  operation.  Wiping  with  a 
toicel  should  be  avoided,  as  a  number  of  linen  fibers  are  detached  thereby  and  remain  adherent 
to  the  teeth  of  the  saw.     Sterilization  by  boiling  in  wahr  is  still  better. 

h.  Mildly  Septic  Cases. — The  second  group  contains  casex  character- 
ized by  chronic  suppuration,  due  to  tuberculosis  of  joints  or  bones,  or  to 
ulcerative  processes  of  various  kinds  requiring  amputation.  Infection  of 
the  amputation  wound  througli  contact  with  hands  or  apparatus  that  have 
touched  the  ulcers  or  fistula?,  or  through  escaping  secretions,  occurs  very 
easily  in  these  cases,  and  special  precautions  have  to  be  emj^loyed  to  avoid  it. 

A  careful  examination  of  the  affected  parts  should  be  made  several  days 
or  a  week  before  the  time  appointed  for  the  amputation.  Abscesses  should 
be  incised  and  drained,  retentions  removed  by  counter-incision,  and  the 
amount  of  secretion  reduced  by  all  knofe'n  means,  as,  for  instance,  frequent 
irrigation  and  change  of  dressings. 

The  field  of  operation  should  be  prepared  as  indicated  for  the  first 
group.  Immediately  preceding  the  operation  the  suppurating  focus  or 
ulcer  should  be  irrigated  and  dressed  in  bed,  and  over  the  usual  dressing  a 
piece  of  rubber  tissue  should  be  tightly  bandaged  so  as  to  overlap  it  on  all 
sides,  the  margin  of  the  gutta-percha  adhering  to  the  skin. 

The  patient  being  anaesthetized,  Esmarch's  constrictor  is  applied,  and  the 
rubbers  are  arranged  in  the  proper  manner  to  shield  the  patient's  body  from 
drenching  with  the  irrigating  fluid.  After  this  the  whole  surface  of  the 
limb,  with  the  exception  of  the  field  of  operation,  is  wrapped  in  clean 
towels,  the  carbolized  towel  covering  the  site  of  the  operation  is  removed, 
this  and  all  hands  are  finally  disinfected,  the  irrigator  is  started,  and  the 
amputation  should  commence. 

It  is  not  very  diflBcult  in  these  cases  to  exclude  suppuration  and  to  secure 
primary  union  by  the  exercise  of  a  moderate  amount  of  care  and  by  intelli- 
gent attention  to  important  details.  Should  infection  occur  on  account  of 
faulty  management  or  the  inherent  difficulty  of  the  case,  the  inevitable  sup- 
puration will  be  mostly  of  a  benign  character,  and  well-nourished  and  well- 
coapted  portions  of  the  wound  may  even  heal  by  primary  union. 

Where  amputation  has  to  be  done  through  ulcerating  or  supjjurating lyarts 
of  a  limb,  the  surgeon  has  a  still  more  difficult  problem  to  solve.  But  even 
in  some  of  these  cases  primary  union  can  be  achieved.  Before  commencing 
the  operation,  the  skin  surrounding  the  ulcer  or  sinus  must  be  thoroughly 
scrubbed  with  brush,  soap,  and  water,  then  the  ulcer  or  sinus  is  repeat- 
edly washed  or  injected  with  an  eight-per-cent  solution  of  chloride  of  zinc, 
and  the  granulations  are  thoroughly  scraped  off  with  the  sharp  spoon.  In- 
durated or  poorly  nourished  tissues  are  removed,  and  all  debris  is  washed 


SPECIAL   APPLICATION   OF   THE  ASEPTIC   METHOD. 


67 


away  with  the  irrigating  stream  of  mercurial  lotion.  After  this  the  ampu- 
tation is  done  as  usual,  good  care  being  taken  to  provide  for  ample  drain- 
age, either  by  means  of  rubber  tubes,  or  preferaily  hy  packing  from  the 
bottom  ivith  iodoform  gauze. 

c.  Septic  Cases  of  Geeater  Inteistsity. — To  the  third  group  belong 
all  cases  in  which  an  acute  progredient  septic  23rocess  of  spontaneous  or 
traumatic  origin  necessitates  ablation  of   the  affected   limb  under  a  vital 


Fig.  49. — Securing  of  visible  ves- 
sels by  artery  forceps. 

indication.  Profusely  sup- 
purating compound  fract- 
ures, rapidly  progressive 
phlegmons  of  the  hand 
and  arm,  cases  of  embolic 
or  other  forms  of  sponta- 
neous gangrene,  compose  this  class,  in  which  the  surgeon  has  to  contend 
not  only  with  the  local  trouble,  but  also  frequently  with  a  deep  and  dan- 
gerous general  intoxication  of  the  system,  due  to  the  massive  absorption 
of  ptomaines  and  bacteria. 

In  many  of  these  cases  the  processes  determining  phlegmonous  destruc- 
tion have  progressed  beyond  the  highest  limit  of  amputation,  and  securing 
of  an  aseptic  state  of  the  wound  is  impossible.     No  amount  of  irrigation 
will  here  do  any  good,  and  the  surgeon,  having  removed  most  of  what  is  a 
11 


68 


EULES  OF  ASEPTIC  AND   ANTISEPTIC  SURGERY. 


source  of  further  infection,  has  to  trust  to  good  luck  and  the  power  of 
resistance  of  liis  patient,  aided  by  ample  stimulation  and  other  restorative 
measures.     In  these  cases  the  open  after-treatment  is  in  order. 

But,  even  in  those  instances  where  amputation  can  yet  be  done  in 
healthy  tissues,  preservation  of  an  aseptic  state  is  an  extremely  difficult 
matter  on  account  of  several  reasons.  First  of  all,  we  have  profuse  secretion 
of  pus  or  ichor,  containing  an  extremely  virulent  culture  of  micro-organisms, 
a  few  individuals  of  which  are  sufficient  to  start  up  another  phlegmon. 
Xobody  who  has  not  tried  it  can  conceive  the  difficulty  of  keeping  free 
from  contamination  in  such  cases.     Another  difficulty  lies  in  the  limits  to 

our  choice  of  the 
place  of  amputa- 
tion. When  we 
can  go  high  up, 
far  out  of  the 
reach  of  the  infec- 
tion, we  should  al- 
ways do  it  without 
regard  to  so-called 
conservative  con- 
siderations. What 
is  first  to  he  con- 
served here  is  the 
life  of  the  imtient^ 
and  before  this 
view  all  objections 
ought  to  vanish. 

But,  when  the 
process  has  extend- 
ed up  beyond  the 
knee  or  the  elbow, 
how  keep  free  from 
contamination  then  ?     True,  the  section 
may  go    through  healthy  tissues ;    but, 
even  with  the  greatest  care,  contact-in- 
fection is  almost  unavoidable. 

The  measures  to  be  employed  in  these 
cases  are  similar  to  those  detailed  for  the 
second  group,  only  with  this  difference : 
that  attention  to  every  step  of  the  prepa- 
ration should  be  more  rigid  :  that,  if  pos- 
sible, tlie  filthy  part  of  the  preparation 
should  be  done  by  a  separate  person  or 
persons ;  and,  finally,  that  the  judicious  use  of  our  strongest  antiseptics  for 
irrigation  (1  :  500  to  1  :  1000  of  corrosive  sublimate)  is  justified.  The  lotion 
used  for  rinsing  the  hands  must  be  repeatedly  changed,  and  everything  that 


ii...  ."  ■.  (  oiiipres.-ioii  of  cut  Mirfaee  b\ 
sponges  placed  over  the  folded  flaps 
Removal  of  constricting'  band. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD. 


69 


lias  come  in  mediate  or  immediate  contact  with  the  focus  of  infection  must 
be  rigidly  rejected. 

Amputation  ivounds  belonging  to  tliis  group  should  not  le  sutured,  hut 
require  loose  packing  and  moist  dressings  {open  treatment). 

Our  first  and  second  groujos  coincide  with  "p)Timary'^  and  ^'  secondary/^ 
the  third  with  "intermediate"  amputations  of  the  old  nomenclature, 

2.  Hsemorrliage. — Esmarch's  apparatus  and  the  animal  ligature  have  un- 
doubtedly had  a  great  share  in  bettering  the  statistics  of  major  amputation, 

a.  Aetificial  Ak^mia. — The  most  important  and  really  blood-saving 
part  of  Esmarch's  apparatus  is  performed  by  the  constricting  band,  used 
instead  of  a  tourniquet.  The  theoretical  advantages  of  the  use  of  the  elastic 
roller-bandage,  employed  for  evacuating  the  vessels  of  the  limb,  are  offset  by 
some  serious  drawbacks.  It  is  an  undeniable  fact  that  the  aerostatic  press- 
ure will  effectually  prevent  the  escape  of  considerable  quantities  of  blood 
from  a  limb,  the  circulation  of  which  has  been  suppressed  by  central  con- 
striction. Therefore,  the  expulsion  of  all  the  blood  contained  in  a  limb  is 
not  an  absolute  requirement  of  blood-saving  in  non-mutilating  ojDerations, 
as,  for  instance,  joint  exsections. 

In  amputations  the  blood  contained  in  the  removed  limb  is  an  absolute 
loss,  but  its  quantity  can  be  effectually  limited  to  a  very  small  amount 


Figs.  51,  5-2. — Esmarch's  artery  forceps. 


Fig.  53. — Ilahn's  artery  forceps. 


Fig.  54. — Showing 
the  difference  be- 
tween a.  a  good, 
and  S,  a  worth- 
less, artery  for- 
ceps. On  com- 
pression, points 
of  a  remain  in 
contact :  those  of 
h  gap. 


by  previous  vertical  elevation  of  the  limb.  And  this  loss  is  abundantly 
repaid  by  the  agreeable  assurance,  that  no  septic  material  or  infectious  cell- 
elements,  detached  from  a  malignant  new-growth,  are  thrown  into  the  gen- 
eral circulation  with  the  blood  and  lymph  which  is  expelled  from  the  dis- 
eased limb  by  the  elastic  roller-bandage. 

The  retention  of  a  certain  quantity  of  blood  in  the  vessels  of  the  stump 
affords  additional  advantages  of  no  mean  value.  By  pressure  upon  the 
stump,  the  smaller  and  smallest  arteries  and  veins  each  will  pour  out  a 
minute  quantity  of  blood,  which  will  greatly  aid  the  surgeon  in  finding  and 


70  RULES  OF  ASEPTIC  AXD  ANTISEPTIC  SURGERY. 

securing  them  before  the  removal  of  the  constrictor.  Thus  all  considerable 
ostia  can  be  occluded,  so  that,  on  detaching  the  rubber  band,  no  spurting 
vessels  will  be  observed,  and  the  capillary  oozing  will  easily  be  controlled  by 
compression  of  the  wound,  aided  by  digital  pressure 
exerted  upon  the  main  artery  of  the  limb.  Com- 
pression should  not  be  done  by  packing  the  wound 
full  of  sponges,  and  folding  the  skin-flaps  over  these. 
True  that  their  elastic  pressure  will  check  hjemor- 
rhage.  But,  on  the  other  side,  most  of  the  small 
thrombi  occluding  the  vessels,  that  are  continuous 
with  the  clot  occupying  the  outer  meshes  of  the 
sponge,  are  torn  away  when  the  latter  is  removed, 
and  renewed  oozing  results.  The  same  objection 
must  be  raised  ao-ainst  vigorous  spoucring  of  the      Fig.  55.— Manner  of  tying 

^  ^  1       B     c  vessel.     (Lsmarcn.) 

wound-surface.      Even  after  oozing    has   stopped 

completely,  frequent  sponging  is  apt  to  renew  it,  and  thus  to  prolong  the 

time  required  for  stanching  the  haemorrhage. 

A  better  way  of  employing  compression  is  to  fold  the  flaps  over  the  wound, 
and  then  to  arrange  the  sponges  outside  of  them.  This  will  insure  the  good 
effect  of  compression  witbout  the  disadvantage  mentioned  above  (Fig.  50). 

As  soon  as  all  visible  vessels  have  been  secured,  the  wound  is  compressed, 
and  the  constrictor  is  removed  while  the  limb  is  held  vertically.  The  assist- 
ant who  removed  the  constricting  band  applies  digital  compression  to  the 
main  artery.  Immediately  after  removing  tbe  rubber  band,  the  skin  of 
the  parts  that  had  been  subjected  to  artificial  antemia  is  seen  to  flush  up, 
and  to  remain  vividly  red  for  from  five  to  ten  minutes.  This  is  the  period 
of  excessive  hyperaemia,  due  to  paresis  of  the  vasomotor  nerves.  Hyperemia 
is  all  the  more  lasting  and  intense,  the  longer  and  the  tighter  was  the  con- 
striction. Attention  should  be  devoted  by  the  surgeon  to  learn  the  exact 
amount  of  tension  of  the  rubber  required  to  just  stop  arterial  circulation. 

The  band  should  never  be  applied  before  the  patient  is  relaxed,  and  it 
should  not  remain  on  longer  than  absolutely  necessary. 

Note. — The  rubber  constrictor  exerts  an  enormous  amount  of  constant  and  undiminishing 
pressure,  hence  it  must  be  used  with  discretion.  Apphing  it  to  the  thigh  held  in  flexion  may 
lead  to  rupture  of  all  flexors  if  the  limb  is  straightened  out  afterward. 

For  a  number  of  years,  the  author  has  discarded  all  specially  made 
bands  and  apparatus  recommended  by  authors  and  sold  by  dealers  for  the 
production  of  artificial  anaemia, 

A  piece  of  pure  gum-elastic  tuliiuj,  of  the  thicTcness  of  a  man's  index- 
finger  or  thumb,  and  of  the  length  of  one  and  a  quarter  yard,  is  all  that  is 
necessary.  Its  application  is  illustrated  in  Fig.  56,  The  limb  being  held 
vertically  for  a  few  minutes,  the  elastic  tube  is  put  on  the  stretch,  and  thus 
coiled  about  the  limb  once  or  twice,  its  tension  and  the  number  of  turns 
being  determined  by  the  relative  thickness  of  the  limb,  the  muscularity, 
and  amount  of  adipose  tissue  underlving  the  skin.     To  estimate  the  tension 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD. 


71 


Fig.  56. 


required,  the  feel  of  the  radial  and  dorsalis  pedis  arteries  may  serve  respect- 
ively.    As  soon  as  their  pulsation  disappears,  the  constriction  is  sufficient. 

When  the  required 
amount  of  constriction 
is  secured,  the  ends  of 
the  tube  are  crossed, 
a  short  piece  of  cord 
or  muslin  bandage  is 
passed  under  the  cross- 
ing, and  is  firmly  tied 
in  a  slip-knot.  The 
ends  of  the  tube  being 
released,  the  rubber 
crowds  up  against  the 
cord,  and  can  not  slip. 
(Fig.  57.) 

This  mode  of  con- 
striction is  very  ener- 
getic, and  deserves  the 
preference  for  very 
large  and  muscular  ex- 
tremities. 

Another  practical 
and  more  gentle  way 
of  applying  elastic  constriction  is  by  means  of  an  ordinary  pure  gum  roller 
or  Martinis  elastic  bandage.  It  is  especially  suited  for  emaciated  limbs  and 
for  operations  on  wo- 
men of  delicate  frame, 
and  children. 

The  manner  of  ap- 
plying Martin's  band- 
age is  well  illustrated 
in  the  accompanying 
cuts.  As  many  turns 
of  the  bandage  are 
superimposed  tightly 
around  the  limb  as 
necessary.  The  last 
turn  is  grasped  in 
the  left  hand,  and  is 
pulled  away  forcibly 
from  the  limb,  form- 
ing a  bight,  into  which  Fig.  57.— Elastic  constrictor  in  situ. 

is  thrust  the  remain- 
der of  the  roller.     As  soon  as  the  left  hand  releases  the  loop,  it  tightens 
about  the  roller,  and  holds  it  in  place  firmly  and  securely.     (Fig.  58.) 


-Manner  of  applying  elastic  constrictor  (rubber  tube) 
for  the  production  of  artificial  ansemia. 


i2 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


/ 


b.  Ligatures  and  Final  H^mostasis. — The  visible  lumina  of  all  cut 
vessels — veins  and  arteries — are  tied  with  catgut,  which  is  in  every  way  pref- 
erable to  silk.  The  objections  raised  against  the  new  material  have  been 
entirely  disproved  by  experience.  The  author  never  saw  one  case  of  sec- 
ondary haemorrhage  from  a  vessel  tied  with  catgut ;  and  knows  of  two  cases 
only,  quoted  on  pages  5  and  57  respectively,  where  catgut  ligatures  slipped 
or  gave  way.  In  both,  very  brittle  catgut  was  used,  and  the  knot  was  not 
sufficiently  tightened  on  account  of  the  fear  of  breakage.  Therefore  it  may 
be  said  that  improper 
material  was  improperly 
applied  in  both  of  these 
instances. 

In  tying  larger  ves- 
sels it  is  very  necessary 
to  grasp  and  withdraw 
them  from  their  sheaths 
for  inspection. 

Arteries  will  some- 
times be  laterally  nicked 
just  a  little  above  the 
transverse  section,  and 
the  ligature  must  be  ap- 
plied above  the  lateral 
opening. 

Large  vems  must  be 
also  well  inspected,  as 
it  may  happen  that  the 

lumen  of  a  hastily  tied  vein  may  be  only  partially  occluded  by  the  ligature. 
An  ordinary  artery  forceps  can  not  grasp  at  once  the  entire  circumference 
of  a  principal  vein,  and  the  author  has  repeatedly  seen  only  one  half  of  the 
vein  deligated  in  the  shape  of  a  dog's  ear,  the  remainder  of  the  vein  con- 


-'^/ 


Fig.  58. — a.  Applying  of  Martin's  bandage  as  a  constrictor. 
b.  Martin's  bandage  i?i  situ. 


Fig.  59.— Tlie  wrong  way  of  detaching  the  skin-flap.    The  knife  should  be  held  vertically.   (Esmarch.) 

tinning  to  bleed  in  spite  of  the  ligature.     The  best  way  to  secure  the  entire 
lumen  of  a  large  vein  is  to  grasp  and  withdraw  it  with  one  or  two  forceps 


SPECIAL   APPLICATION   OF   THE  ASEPTIC   METHOD. 


rs 


Fig.  60. — Liston's  bone  forceps. 


until  its  whole  circumference  is  clearly  visible,  and  tlien  to  twist  it  around 

its  own  axis,  when  it  will  be  seen  to  form  a  neck  which  can  be  easily  tied. 
Atheromatosis  of  arteries  is  no  valid  objection  to  the  application  of  the 

catgut  ligature. 

The  grasping  of 

vessels    affected 

by  it  is  diflBcult 

on    account    of 

their  liability  to 

slip  before,  and 

break  after,  be- 
ing caught  by  the  forceps.     The  ligature  must  not  be  tightened  too  much 

on  an  atheromatous  vessel,  or  it  may  cut  through  it. 

Vessels  imbedded  in  sclerosed  tissues  must  be  secured  by  a  circular  stitch. 
After  the  removal  of  the  elastic  constrictor,  local  compression  of  the 

wound  is  kept  up  until  the  marked  hyper^emia  of  the  limb  begins  to  wane. 

Then,  an  assistant  compressing  the  main  artery,  the  wound  is  exj^osed.    The 

glazing  of  clotted  blood  is  re- 
moved by  irrigation  and  gentle 
friction  with  the  tips  of  the 
fingers,  and  the  assistant  is  di- 
rected to  release  the  compressed 
main  artery.  Then  any  addition- 
al vessels  seen  spurting  should 
be  secured.  The  hypereemia  of 
the  limb  will  have  ceased  by 
this  time,  and  with  it  the  ooz- 
ing. 

XoTE.— Should  a  larger  nutrient  ar- 
tery be  divided  at  the  time  of  the  sec- 
tion of  the  bone,  its  bleeding  can  be 
readily  stopped  by  the  insertion  of  a 
short  piece  of  stout  catgut  into  the 
spurting  orifice,  where  it  can  be  left  be- 
hind without  any  harm.  The  employ- 
ment of  wax  for  the  same  purpose  is 
unsafe,  unless  the  material  is  first  ster- 
ilized by  boiling. 

The  statement  that  Es- 
march's  apparatus  is  not  blood- 
saving,  but,  on  the  contrary, 
causes  undue  haemorrhage,  is  misleading.  It  may  be  positively  said  that 
skillful  management  of  the  ajDplication  of  Esmarch's  constrictor  will  enable 
the  surgeon  to  perform  major  operations  with  an  astonishingly  small  amount 
of  haemorrhage,  and  that  loss  of  much  blood  after  the  removal  of  the  rubber 
band  is  due  to  faulty  manipulation. 


-Amputation  woimd  of  thigh, 
drained. 


utured  and 


74 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


3.  Securing  of  a  Good  Stump. — In  circular  amputations,  as  well  as  in 
flap  operations,  an  important  object  should  be  to  gain  abundant  covering, 
and  to  bring  about  easy  and  natural  a^^position  of  the  wound-surfaces  with- 
out   much    external 
pressure. 

In  performing  cir- 
cular amputation,  the 
assistant  holding  the 
mesial  part  of  the 
limb  can  greatly  in- 
fluence the  shape  of 
the  stump.  As  it  is 
desirable  to  produce 
a  wound  of  the  shape 
of  a  hollow  cone, 
multiple  circular  sec- 
tions of  not  too  great 
depth  are  commend- 
able, while  the  assist- 
ant successively  re- 
tracts each  layer  divided  by  the  amjiutating  knife  until  the  periosteum  is 
cut  through  and  pushed  well  back.  The  soft  jiarts  are  inclosed  in  a  two- 
or  three-tailed  compress  of  sublimated  gauze,  and  the  bone  or  bones  are 
sawed  off,  care  being  taken  on  the  leg  and  forearm  to  complete  the  sec- 
tion of  both  bones  simul- 
taneously. After  this  the 
sharp  edges  of  the  bone 
are  clipped  off  with  bone- 
cutting  forceps,  and  the 
vessels  are  attended  to. 

Cutaneous  flaps   make 
a  very  good   covering   to 


Fig.  62. — Amputation  wound  of  leg,  sutured  and  drained.     Keten- 
tive  button  sutures. 


Fig.  63. 
Dressing  of  amputation 
wound  of  the  thiirli. 


most  stumps,  and  can  be  very  easily  adapted.      As  soon  as  the  haemor- 
rhage is  perfectly  under  control,  suture  of  the  wound  can  be  commenced. 


SPECIAL  APPLICATION  OF   THE  ASEPTIC  METHOD. 


<o 


Fig.  64. — Dressing  of  amputation  wound  of 
"the  leg. 


The  author  is  using  exclusively  the  interrupted  suture,  for  reasons  elsewhere 
mentioned. 

If  the  case  was  unimpeachahly  aseptic,  and  no  suj)puration  is  expected, 
one  medium-sized  drainage-tube  will  suffice  to  carry  away  the  first  secre- 
tions.    Otherwise  abundant  ways  of  egress  must 
be  provided  in  the  shape  of  several  properly  dis- 
tributed tubes.    The  protruding  end  of  each  tube 
is  transfixed  with  a  safety-pin,  and  cut  off  on  a 
level  with  the  skin.    An  ample  dry  dressing,  con- 
sisting of  a  few  layers  of  iodoformed  and  a  gen- 
erous  mass   of    sublimated   gauze    is 
snugly  bandaged  to  the  stump,  so  as 
to  reach  at  least  twelve  inches  above 
the  line  of  section. 

If  proper  care  was  devoted  to  the 
stanching  of  the  hEemorrhage,  no  great 
pressure  will  be  required  to  check  the 
oozing,  which  is,  anyway,  moderate 
after  the  use  of  corrosive  sublimate 
for  irrigation. 

The  idea  of  bringing  about  close 
apposition  of  the  wound-surfaces  by 
energetic  pressure  is  not  to  be  culti- 
vated, as  it  will  lead  to  frequent  marginal  necrosis  of  the  flaps,  frustrating 
•complete  primary  union.  Surface  apposition  should  rather  be  accomplished 
iDy  a  proper  fashioning  of  the  wound  and  flaps, 
and  the  sutures  should  exert  no  traction  what- 
ever, but  should  merely  secure  contact  of  the 
cutaneous  edges. 

For  securing  contact  of  the  deeper  portions  of 
■an  amputation  wound,  Lister's  lead-plate,  or  but- 
ton, sutures  are  very  advantageous.     (Fig.  62.) 

Note. — In  former  times,  when  car- 
"bolic  lotions  were  employed  for  irriga- 
tion, oozing  used  to  be  quite  free,  and 
"necessitated  the  use  of  a  good  deal  of 
pressure,  which  was  somewhat  tempered 
"by  the  interposition  of  thick  layers  of 
borated  cotton  between  the  dressing 
proper  and  the  outer  bandage.  Flap 
necroses  were  then  much  more  com- 
mon than  nowadays. 

The  sole  office  of  the  dress- 
ings is  to  lightly  support  the 
wound,  and  to  absorb  and  ren- 
der innocuous  the  secretions. 
12 


Fig.  65. — Ampiitation  wound  ot"  tlie  thigh  fourteen 
days  after  the  operation.     Case  of  Mrs.  Walther. 


76 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


The  iuithor's  custom  is  to  make  the  first  change  of  dressing  on  the 
fourth  day  after  the  operation,  when  the  drainage-tubes  cau  be  withdrawn. 
Another  lighter  aseptic  dressing  is  then  applied,  and  remains  undisturbed 
for  a  week.  By  the  end  of  this  time  the  drainage-tracks  will  have  either 
healed  completely,  or  their  place  will  be  marked  by  a  small  patch  of  granu- 
lations, requiring  merely  a  borated-salve  or  simple  adhesive-plaster  covering. 

This  refers  to  correct  cases  only.  Should  septic  fever  develop  or  mar- 
ginal gangrene  be  noted,  frequent  moist  dressings  are  in  order,  and  the  rules 
appropriate  for  the  treatment  of  suppurating  wounds  obtain  precedence. 

Case:  Illustrating  a  Correct  Course  of  Healing. — Mrs.  Panline  "Walther,  seam- 
stress, aged  fifty-one.  Far-gone  tuberculous  destruction  of  knee-joint  with  fistula,  the 
latter  the  result  of  a  previous  exploratory  incision.  Feb.  IJfth. — Amputation  of  thigh 
in  middle  third.  Aseptic  fever,  with  rise  of  temperature  to  103°  Fahr.,  on  the  two  days 
following  the  operation.  Feb.  18th. — Temperature,  99°  Fahr.  March  1st. — First 
change  of  dressings ;  drainage-tubes  removed  ;  wound  redressed.  March  7th. — Wound 
completely  healed,  except  wliere  one  minute  spot  of  granulations  marks  the  former  site 
of  a  tube.  March  12th. — All  firmly  cicatrized;  the  stump  can  be  lightly  pounded 
without  pain.     March  17th. — Patient  discharged  cured.     See  Figs.  61  and  65. 


IV.     OPERATIONS    ABOUT    NON-SUPPURATING    JOINTS. 

1.  Puncture  and  Irrigation.— Chronic  hydrops,  or,  as   Volkmann  calls 
it,  catarrhal  synovitis  of  the  knee-joint,  is  often  benefited  or  even  cured 
by  puncture  and  subsequent  irrigation. 

Schede's  rule  of  using  corrosive  sublimate  (1 : 1,000) 
whenever  the  synovial  fluid  is  turbid,  and  carbolic 
lotion  (three  per  cent)  when  it  is  clear,  can  be  com- 
mended as  rational.      In   the  former   case  pyogenic 
elements  cause  the  production  of  a  certain  amount  of 
leucocytes,  and  hence  the  use  of  a  strong  germicide 
like  corrosive  sublimate  is  appropriate. 
Simple  hydrops,  where  there  is  no  ad- 
mixture of  pus-cells,  is  comparable  to 
bursal   hydrops  or   hydrocele,   and    is 
benefited  by  the  ap- 
plication of  an  irri- 
tant  substance   like 
carbolic  acid. 

The  manner  of 
procedure  employed 
by  the  author  is  as 
follows  : 

Two    large -cali- 
bered  trocars  are  ren- 
dered aseptic  either 
by  boiling  the  tubes  for  an  hour  in  a  five-per-cent  solution  of  carbolic  acid, 
or  by  heating  them  in  a  large  alcohol  flame  to  incandescence,  after  which 


Irrigation  of  kuee-joint. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD. 


11 


they  are  dropped  into  carbolic  lotion.  Too  much  care  can  never  be  exer- 
cised in  attending  to  the  proper  disinfection,  of  the  trocar-tubes,  as  their 
hollow  shape  renders  their  cleansing  a  difficult  matter  at  best. 

Case. — Thomas  Casey,  hostler,  aged  twenty-three.  Hydrops  of  right  knee-joint 
of  several  years'  standing.  March,  I4,  1887. — Puncture  and  irrigation  with  Thiersch's 
solution  and  carbolic  lotion.  Dorsal  splint.  The  trocars  had  received  a  rather  super- 
ficial attention  by  boiling  of  too  short  duration.  The  following  day  high  fever  appeared 
with  great  distention  of  the  joint.  March  15th. — Aspiration  yielded  pus.  March  16th. 
— Multiple  incision  and  drainage.  The  fever  not  abating,  although  secretion  was  very 
scanty,  the  limb  was  suspended  in  a  wire  cradle,  and  weight  extension  was  applied,  so 
as  to  enable  the  house-surgeon  to  frequently  irrigate  the  joint  without  disturbing  the 
patient's  rest.  In  spite  of  the  most  attentive  treatment,  new  abscesses  developed,  and 
the  patient's  evident  failing  finally  compelled  amputation  of  the  thigh,  which  was  done. 
May  30th,  by  Dr.  F.  Lange.  The  patient  recovered.  Extensive  tuberculosis  of  the  head 
and  shaft  of  the  tibia  was  ascertained  by  examining  the  specimen. 

After  the  usual  preparation  of  the  patient's  limb,  the  trocars  are  thrust 
into  the  knee-joint  from  opposite  sides,  and  the  synovial  fluid  is  let  out. 

To  remove  flocculse  of  coagulated  fibrin,  Thiersch's  solution  is  first  used 
for  washing  out  the  Joint  cavity.  The  reason  for  this  is  the  fact  that  car- 
bolic acid  hardens  the  fibrinous  clots  and  makes  them  tough  and  unfit  to 
pass  the  cannula.  Corrosive  sublimate,  on  the  other  hand,  is  poisonous, 
and  dangerous  quantities  of  it  may  be  absorbed  if  irrigation  be  carried  on 
sufficiently  long  to  free  the  Joint  of  all  deposits  of  fibrin. 

CASE.-^John  Schurz,  mason,  aged  thirty,  chronic  hydrops  of  knee-joint.  Ajjril  8, 
1886. — At  the  German  Hospital,  double  puncture  and  rather  prolonged  irrigation  with 
corrosive-sublimate  lotion  (1  : 1,000)  on  account  of  the  presence  of  large  quantities  of 
fibrinous  deposit.  April  10th.  —Mercurialism  ;  salivation  and  sharp  colic,  lasting  for  five 
days,  with  some  fever,  ending  in  recovery  on  appropriate  treatment.     Hydrops  cured. 

As  soon  as  Thiersch's  fluid  is  seen  to  escape  clear  from 
the  efferent  cannula,  corrosive  sublimate  or  carbolic  lotion 
is  substituted  therefor,  and  the  Joint  is  thoroughly  flushed 
with  it.  To  prevent  the  retention  of  a  dangerous  amount 
of  either  of  these  solutions,  the  Joint  is  flexed  and  emptied 


Fig.  67.— Volkman's  T-splint. 

Iby  external  pressure.  The  tubes  are  withdrawn,  a  small  patch  of  iodoform 
gauze  is  attached  with  a  strip  of  adhesive  plaster  over  each  puncture-hole, 
:and  the  limb  is  placed  on  a  dorsal  splint.     (Fig.  67.) 


Y8  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

2.  Arthrotomy  for  Chronic  Fibrinous  Hydrops,  for  Vegetations,  Tumors, 
and  Floating  Bodies  of  the  Knee-joint,  a.  Hydrops  Genu.— In  cases 
where  a  thick  coating  of  ilbrinous  dei)Osit  is  lining  the  entire  cavity  of  the 
knee-joint,  simple  puncture  and  irrigation  will  be  found  impracticable  on 
account  of  the  continuous  clogging  of  the  efferent  cannula.  To  completely 
free  the  joint  of  these  masses,  immediate  incision  must  be  done.  The  in- 
ternal aspect  of  the  knee  presents  the  most  convenient  place  for  this  pro- 
cedure. The  skin  and  fascia  are  successively  incised,  and  all  bleeding  vessels 
are  carefully  tied.  On  being  exposed,  the  bluish  capsule  is  cut  into,  and 
the  incision  is  extended  to  about  an  inch  in  length.  After  this,  irrigation 
by  Thiersch's  solution  is  practiced,  and  the  joint  is  repeatedly  flexed  and 
extended  to  aid  detachment  and  expulsion  of  the  membrane,  which  can  be 
hastened  by  sweeping  the  index-finger  through  all  the  recesses  of  the  joint. 
The  slight  haemorrhage  following  this  manipulation  will  cease  spontane- 
ously, and  the  clots  are  washed  out  by  a  strong  jet  of  irrigating  fluid. 


Fig.  68. — Arraugeiueut  nf  rubber  sheets  for  operations  about  tiie  lower  extremity. 

After  the  insertion  of  a  short  piece  of  medium-sized  drainage-tube,  which 
should  reach  just  within  the  cavity  of  the  joint,  the  capsular  incision  is 
closed  by  a  few  interrupted  catgut  sutures. 

The  fascia  and  skin  are  likewise  united,  the  protruding  end  of  the  tube 
is  transfixed  with  a  safety-pin  and  trimmed  off  short,  and  the  joint  receives  a 
final  flushing  with  carbolic  or  mercurial  lotion  according  to  the  indications 
mentioned  in  the  preceding  paragraph. 

After  this  the  wound  is  dressed  and  the  limb  is  fixed  upon  a  dorsal  splint. 

If  the  aseptic  measures  were  sufficient,  no  reaction  whatever  will  follow 
the  operation.  In  cases  where  the  hydropic  fluid  was  limpid,  no  secretion 
of  any  account  will  be  observed,  and  the  tubes  can  be  withdrawn  at  the  first 
change  of  dressings,  which  is  usually  done  on  the  fifth  day  after  the  opera- 
tion. As  soon  as  the  wound  is  in  progress  of  cicatrization,  active  movements 
and  cautious  use  of  the  limb  should  commence,  the  joint  being  protected 
by  a  small  aseptic  dressing,  held  in  place  by  Martin's  elastic  bandage. 

Case  of  .John  Scliurz,  page  T7,  who  was  discharged  cured  June  29,  1886,  with 
partially  restored  and  constantly  improving  mobility. 

Passive  movements  are  unnecessary  and  very  painful.  Restoration  of 
the  mobility  should  be  hastened  by  cold  or  warm  douching  and  subsequent 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.  79 

massage,  and  its  final  establishment  left  to  the  active  efforts  of  the  patient 
himself. 

Cases  in  which  large  quantities  of  firmly  adherent  membrane  were 
removed  and  some  hsemorrhage  followed,  especially  if  the  hydropic  fluid 
was  very  turbid,  will  develop  a  moderate  secretion  of  serous  bland  pus,  that 
may  continue  for  some  time.  Some  fever  will  also  occur,  to  subside  as  soon 
as  the  dressings  are  changed  and  the  joint  is  washed  out  again. 

It  will  commend  itself  to  apply  in  these  cases  a  fenestrated  plaster-of- 
Paris  splint,  and  to  repeat  irrigation  once  or  twice  daily  in  the  beginning, 
diminishing  the  number  of  washings  ^ari  passu  with  the  disappearance  of 
the  secretion.  As  soon  as  the  discharge  shall  have  become  serous  and 
scanty,  the  tube  can  be  withdrawn  and  the  case  treated  as  above  explained. 

Case. — Fred.  Schecker,  laborer,  aged  twenty-six,  had  been  suffering  for  several 
years  from  a  painless,  massive,  hydropic  distention  of  the  right  knee-joint,  that  could 
not  be  traced  to  a  traumatism.  Considerable  lateral  mobility  was  the  main  cause  of  his 
seeking  relief  at  Mount  Sinai  Hospital.  Dec.  7,  1885. — Double  puncture  and  irriga- 
tion were  done,  but  had  to  be  abandoned,  on  account  of  large  masses  of  dense  fibrin. 
Immediate  incision  and  clearing  of  the  joint  were  practiced.  Fever  and  some  secretion 
being  noted,  the  dressings  were  changed  December  10th,  and,  the  limb  being  put  up  in 
a  fenestrated  plaster  sphnt,  irrigation  with  corrosive  sublimate  was  employed  twice — 
later  on,  once — daily.  Dec.  20th. — Normal  temperature  was  noted.  Feb.  1st. — Irriga- 
tion discontinued  and  splint  removed.  Feb.  20t7i. — Patient  discharged  cured,  with 
increasing  flexion  (twenty  degrees). 

i.  Vegetatioi^s. — The  favorite  seat  of  vegetations  in  the  knee-joint  is 
that  lax  part  of  the  capsule  situated  beloAV  the  inferior  margin  of  the  patella, 
which  is  overlaid  by  a  thick  cushion  of  loose  fat  and  the  ligamentum 
patellae  proprium.  They  are  rarely  pedunculated,  their  common  appear- 
ance being  that  of  a  yellowish  or  purple  coxcomb,  and  their  direction  trans- 
verse. The  functional  disturbance  produced  by  them  is  sometimes  very 
slight,  but  occasionally  extremely  severe,  especially  when  it  happens  that 
their  margin  is  caught  and  jammed  in  between  the  articular  surfaces. 
Haemorrhage  with  acute  synovitis  and  an  effusion  may  follow  this  accident. 

The  diagnosis  of  vegetations,  sufficiently  massive  to  cause  functional 
trouble,  is  not  difficult  to  the  careful  examiner.  Frequently  the  patients 
themselves  will  point  out  the  kernel-like  slijoping  bodies  of  soft  consistency. 
They  are  easily  distinguished  from  free  floating  bodies  by  the  fact  that  on 
manipulation  they  never  disappear  entirely  from  their  seat  of  predilection, 
to  reappear  in  a  distant  part  of  the  joint. 

Topical  treatment  is  generally  powerless  against  this  complaint, 
although  the  constant  use  of  a  Martin's  bandage  may  mitigate  the  trouble 
by  confining  somewhat  the  motion  of  the  joint,  and  thereby  diminishing  the 
chances  of  contusion  of  the  growths  by  jamming. 

In  aggravated  forms,  arthrotomy  and  excision  of  the  vegetations  is 
proper.  With  strict  attention  to  the  cautete  before  mentioned,  the  joint  is 
incised,  and,  the  patella  being  tilted  upward  by  a  sharp  retractor,  the  mass 
is  grasped  with  a  pair  of  mouse-tooth  forceps,  and  is  bodily  excised.     Should 


80  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

it  extend  across  the  entire  width  of  the  patella,  another  lateral  incision  will 
have  to  be  made  on  the  opposite  aspect  of  the  knee,  to  enable  the  surgeon 
to  complete  the  excision. 

If  much  hyperaemia  of  the  growth  be  present,  as  shown  by  its  purplish 
color,  ha?morrhage  may  be  rather  free.  In  such  a  contingency  the  raw  sur- 
face should  be  seared  with  the  thermo-cautery. 

Toilet  of  the  joint  cavity  is  followed  by  suture,  and  a  small  drainage- 
tube  is  inserted  to  serve  as  a  safety-valve.  The  subsequent  treatment  coin- 
cides with  that  given  for  simple  hydrops  after  puncture  and  irrigation. 

Case  I. — Miss  Lena  C,  aged  fourteen,  A^egetations  occupying  the  internal  inferior 
margin  of  the  patella.  The  patient  had  frequent  attacks  of  sudden,  very  sharp  pain 
in  the  knee,  followed  by  effusion.  A'arious  plans  of  local  treatment  had  been  em- 
ployed unsuccessfully  for  about  a  year.  Dec.  5,  1881. — With  the  assistance  of  Dr.  B. 
Scharlau,  the  family  attendant,  incision  of  knee-joint  on  its  inner  aspect  was  done. 
A  series  of  yellow,  smooth  bodies  presenting,  they  were  excised  with  forceps  and 
curved  scissors.  Drainage,  suture,  and  plaster- of-Paris  splint.  Some  fever,  due  to 
constipation,  but  no  inflammation  followed.  Dee.  9th. — A  laxative  being  administered, 
a  copious  stool  was  had,  whereupon  the  temperature  at  once  fell  to,  and  remained  at 
the  normal  standard.  Dec.  12th. — The  tube  was  removed.  About  New  Year's  the 
patient  commenced  to  walk  about,  and  shortly  after  was  discharged  cured.  In  the 
spring  of  1886  circumscribed  swelling  of  the  synovial  membrane  in  the  vicinity  of  the 
cicatrix  was  noted.  It  subsided  upon  the  use  of  an  elastic  bandage,  which  was  ulti- 
mately abandoned.     In  January  of  1887  the  patient  was  still  perfectly  well. 

Case  II. — Frank  Mann,  clerk,  aged  twenty-five,  well-defined  painful  vegetations 
to  be  felt  near  the  lower  margin  of  the  knee-pan,  on  both  sides.  Duration  of  trouble, 
six  months.  Functional  disturbance  very  marked.  Ajn^il  8,  1886. — Double  incision 
of  knee-joint  at  the  German  Hospital.  Excision  of  a  deep-red,  transversely  situated, 
coxcomb-like  growth  from  the  lower  rim  of  the  patella.  A  good  deal  of  oozing  neces- 
sitated searing  of  the  denuded  surface  of  the  capsule  with  the  thermo-cautery.  Drain- 
age; plaster-of-Paris  splint.  Eventless  course  of  healing.  The  tube  was  removed  on 
the  tenth  day.     Patient  dischai'ged  cured,  with  good  motion.  May  20,  1886. 

c.  Floating  Bodies  of  the  Knee-Joint  : 

Case. — E.  Behrmann,  painter,  aged  thirty-eight.  Large  floating  body  of  the  knee- 
joint,  with  chronic  hydrops.  May  15,  1886. — Arthrotomy  at  the  German  Hospital. 
Previous  to  the  incision  the  floating  body  was  fixed  by  finger-pressure  near  the  line  of 
section,  but  disappeared  in  the  joint  cavity  when  the  last  stroke  of  the  knife  opened 
the  capsule.  The  author  swept  through  the  joint  with  a  well-rinsed  finger,  and  found 
the  body  in  the  bursa  of  the  quadriceps  muscle.  By  means  of  bimanual  manipulation, 
the  body  was  brought  down  to  the  aperture,  and  was  readily  extracted.  Irrigation 
with  corrosive-sublimate  lotion,  drainage,  suture,  and  fixation  upon  a  dorsal  splint  fol- 
lowed the  extraction.  Normal  course  of  healing.  June  15,  1886. — The  patient  was 
discharged  cured  with  good  function  of  the  knee. 

d.  Sutueing  of  the  Fractueed  Patella. — Although  not  perfect, 
yet  the  functional  results  achieved  by  the  ordinary  forms  of  treatment  em- 
ployed in  cases  of  transverse  fracture  of  the  patella  are  generally  so  good, 
that  arthrotomy,  for  the  sake  of  wiring  or  otherwise  suturing  the  patellary 
fragments,  is  rarely  if  ever  justified  at  a  time  immediately  following  the 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.  81 

injury.  Hamilton  has  shown  that  even  a  considerable  degree  of  diastasis 
of  the  fragments  is  not  incompatible  with  a  very  fair  functional  ability  of 
the  limb,  provided  that  the  intervening  ligamentous  band  be  strong,  the 
action  of  the  quadriceps  vigorous,  and  the  lateral  extensions  of  the  quadri- 
ceps tendon  uninjured. 

It  seems,  then,  rational,  in  cases  of  patellary  fractures,  first  to  employ 
the  usual  methods  of  treatment  by  rest  and  appropriate  bandaging,  and  thus 
to  await  the  result.  It  never  can  be  predicted  with  accuracy,  and  may  turn 
out  to  be  very  satisfactory  after  all. 

Should  the  result  be  unsatisfactory,  either  through  failure  of  union  or 
subsequent  rupture  of  the  new-formed  ligament,  arthrotomy  and  secondary 
suture  may  properly  be  taken  into  consideration. 

On  account  of  the  presence  of  large  quantities  of  blood  and  serum,  found 
shortly  after  the  accident  effused  into  the  Joint  and  its  vicinity,  primary 
arthrotomy  for  patellary  fracture  is  a  more  risky  undertaking  than  the  sec- 
ondary operation.  The  slightest  error  in  the  use  of  the  aseptic  apparatus 
may  cause  irreparable  damage,  and  may  cost  the  patient's  limb  or  life. 
Especially  dangerous  are  those  cases  in  which  open  ulcers  or  abrasions,  or 
other  secreting  wound-surfaces  due  to  the  primary  injury,  are  located  near 
the  field  of  operation,  be  they  however  small  or  superficial.  Pyogenic  in- 
fection and  suppuration  of  the  knee-joint  are  here  nigh  to  inevitable. 
Anchylosis  is  the  most  favorable  issue  that  can  be  expected  in  case  of  sup- 
puration ;  very  often,  however,  the  limb  will  have  to  be  sacrificed. 

The  conditions  for  the  successful  performance  of  the  secondary  opera- 
tion are,  as  far  as  the  chance  of  avoiding  suppuration  is  concerned,  infinitely 
better.  The  effusions  due  to  recent  traumatism  are  mostly  absorbed,  the 
parts  have  recovered  their  physiological  equilibrium,  and  faults  of  aseptic 
technique  are  easier  to  avoid  and  not  as  hard  to  remedy  as  in  recent  cases. 

The  circumstance  can  not  be  urged  as  a  serious  drawback,  that  a  few 
weeks  after  the  accident,  the  fracture-planes  are  found  covered  with  new- 
formed  connective  tissue  or  a  cicatrix,  and  that  this  must  be  first  removed 
before  suture  can  be  applied. 

More  difficulty  may  be  encountered  in  overcoming  the  retraction  of  the 
quadriceps.  But  even  such  high  degrees  of  retraction  as  are  occasionally 
observed  in  complete  failure  of  union,  or  met  with  in  old  secondary  rupture, 
representing  a  diastasis  of  several  inches,  can  be  managed  so  as  to  permit 
suture  and  bony  union  of  the  fragments. 

The  mode  of  procedure  is  well  illustrated  by  the  following  history  : 

Case.— Mrs.  Lizzie  P.,  housewife,  aged  twenty- eight,  an  extremely  obese  woman, 
contracted  in  1884  a  transverse  fracture  of  the  left  patella,  which  was  attended  to  by 
her  family  physician,  and  was  treated  by  rest  and  bandaging.  It  healed  with  a  seem- 
ingly satisfactory  ligamentous  union,  which,  however,  gave  way  a  few  weeks  after 
the  completion  of  the  treatment,  resulting  in  a  wide  gap  between  the  fragments.  Meas- 
urement gave  a  hiatus  of  two  and  a  half  inches  in  extension,  five  inches  in  flexion  at  a 
right  angle.  Her  gait  was  rather  uncertain,  causing  many  falls,  one  of  which  produced, 
May  2, 1887,  a  transverse  fracture  of  the  HgM  patella.    This  recent  fracture  was  treated 


82  RULES  OP  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

by  approximation  with  two  broad  strips  of  adhesive  plaster,  bandaged  on  and  laced, 
the  limb  resting  on  a  T-splict.  May  25th. — Tbe  old  patelLiry  fracture  was  united  by 
operation  at  tlie  German  Hospital.  The  limb  having  been  rendered  anaemic  by  con- 
striction, the  joint  was  laid  open  by  a  transverse  incision,  and  the  cicatricial  tissue 
investing  the  fracture-planes  of  the  knee-pan  was  cut  away,  and  the  bone  scraped  free 
from  all  adhering  connective  tissue,  until  the  corresponding  -surfaces  of  the  ])ate]la 
were  clean  and  smooth.  After  this  four  equidistant  holes  were  drilled  through  each 
fragment,  while  the  bone  under  treatment  was  held  immovably  fixed  by  an  assistant 
in  the  grasp  of  a  lion-jaw  forceps.  The  drilling  of  the  apertures  in  the  upper  fragment 
was  much  easier  than  of  those  in  the  lower  one.  By  the  aid  of  a  flexible  silver  probe, 
a  double  thread  of  thick  catgut  (No.  4)  was  drawn  through  the  corresponding  drill- 
holes, the  ends  of  each  suture  being  temporarily  secured  in  the  grip  of  an  artery  for- 
ceps. The  most  difficult  part  of  the  operation  consisted  in  the  approximation  of  the 
fragments.  The  quadriceps  tendon  was  exposed  by  a  longitudinal  incision  of  six  inches 
in  length,  and,  the  upper  fragment  being  forcibly  drawn  downward  with  bone-forceps, 
a  number  of  alternating  lateral  notches  were  cut  into  the  muscle  and  tendon,  until  the 
fragment  yielded  to  moderate  traction.  The  first  suture  nearest  the  edge  of  the  patella 
was  tightened — not  tied — by  an  assistant  until  the  fragments  were  brought  in  contact, 
whereupon  the  second  suture  was  firmly  knotted.  After  this  the  fourth  suture  was 
tightened  and  the  third  one  tied;  finally,  the  two  outermost  sutures  were  attended  to. 
The  ends  of  the  catgut  were  trimmed,  and  three  short  drainage-tubes  were  inserted  in 
the  three  angles  of  the  wound.  During  the  whole  operation  a  stream  of  a  1  :  2,500 
solution  of  corrosive-sublimate  lotion  was  played  on  the  exposed  tissues.  Before  the 
closure  of  the  wound,  it  was  finally  flushed  with  a  1  :  1,000  mercuric  solution,  and  the 
apjilication  of  a  number  of  external  catgut  stitches  completed  the  process.  The  knee 
was  enveloped  in  an  ample  dry  dressing  and  a  plaster-of-Paris  splint,  enforced  by  a 
few  lateral  strips  of  white-wood  veneering.  Finally,  the  constricting  elastic  band  was 
removed,  and  the  extremity  suspended  in  the  vertical  position,  which  was  abandoned 
twenty-four  hours  after  the  completion  of  the  operation.  June  3d. — Splint  removed ; 
dressings  changed ;  drainage-tubes  withdrawn.  June  17th. — Wound  healed  through- 
out. Silicate  splint  applied.  June  20th. — Patient  commenced  to  walk  on  crutches. 
July  2d. — She  was  discharged  cured.  July  13th. — The  union  of  sutured  patella  was 
found  firm,  the  operated  limb  much  more  useful  than  its  mate.  Flexion  could  be  car- 
ried to  a  right  angle.     The  course  of  healing  of  the  case  was  feverless  throughout. 

3.  Arthrotomy  for  Irreducible  or  Habitual  Dislocation,  and  for  Deformity 
due  to  Fracture. — Dislocations  that  are  irreducible  from  the  outset,  or  have 
become  so  through  neglect,  can  be  corrected  by  means  of  aseptic  ar- 
throtomy. 

Case  I. — Henry  Kohler,  aged  nine.  Dislocation  of  basal  phalanx  of  thumb  upon 
dorsum  of  metacarpal  bone,  of  six  weeks'  standing.  Deceinbet  29,  1879. — Piepeated 
unsuccessful  attempts  at  reduction  under  chloroform.  Immediate  arthrotomy.  Dis- 
section of  abnormal  adhesions,  and  excision  of  a  shred  of  interposed  capsular  tissue, 
followed  by  ready  reduction.  Suture  and  catgut 
drainage.  Primary  union.  Jan.  10th. — Patient 
discharged  cured  with  improving  function. 

Case  II. — John  Becker,  aged  twelve.     Fresh 
compound  dislocation  of  terminal  phalanx  of  the 
ring-finger  on  the  dorsum  of  the  middle  phalanx. 
March  29,  1884.-Eth.r  was  administered  at  the      ^^1n  TornSSsysf ot^htteS 
German  Hospital,  and,  after  careful  disinfection  dislocation. 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD. 


83 


Fig.  70. — Arrangement  of  rubber  sheets  for  npi  i.ttioiis 
about  the  upper  extremity. 


of  the  patient's  hand,  reduction  was  repeatedly  attempted  without  success.  The  small 
transverse  laceration  of  the  integument  of  the  volar  aspect  of  the  finger  did  not  give 
the  least  advantage  as  to  examining  the  interior  relations  of  the  displacement,  hence  a 
lateral  incision  was  made  on  the  radial  side.  It  was  then  ascertained  that  the  tendon 
of  the  flexor  digiti  profundus  was  displaced  upon  the  dorsum  of  the  middle  phalanx, 
and  was  interposed  between  the 
articulating  surfaces.  Eeduc- 
tion  could  only  be  accomplished 
after  a  free  division  of  all  resist- 
ing bands  of  torn  capsular  liga- 
ment, caught  between  the  flexor 
tendon  and  the  articulating  sur- 
faces. Suture  and  catgut  drain- 
age ;  fixation  of  the  finger  on  a 
small  volar  splint.  April  5th. — 
Primary  union.  In  May  the 
function  of  the  injured  joint  be- 
came nearly  normal.  (Fig.  69.) 
Case  III.— John  U.  Kena, 
pnbliean,  aged  thirty-nine.  Ad- 
mitted to  German  Hospital  Feb- 
ruary 9,  1889,  with  old  irre- 
ducible subcoracoid  dislocation  of  right  shoulder-joint.  A  number  of  unsuccessful 
attempts  at  reduction  had  been  made  by  several  medical  men.  February  11th. — Ether 
being  administered,  reduction  by  manipulation  was  again  unsuccessfully  tried.  Ar- 
throtomy  by  a  vertical  anterior  incision  revealed  fracture  by  divulsion  of  the  minor 
tubercle.  The  head  of  the  humerus  was  dissected  out  of  its  newly-formed  adhesions, 
and  was  replaced  in  the  glenoid  cavity.  Drainage  by  a  posterior  button-hole  incision. 
Suture.  Uninterrupted  primary  union  of  wound.  Patient  was  discharged  cured, 
with  improving  mobility,  on  March  16th. 

Condyle  fractures    of  the   elbow   ivitJi   posterior   or   lateral  displace- 
ment of  tlie  forearm  are  a  common  injury  ivitJi  children.     What  with 

the  great  difficulty  of  an 
exact  diagnosis  in  the  pres- 
ence of  a  large  effusion,  and 
the  great  differences  of  ojain- 
ion  of  the  authors  as  regards 
the  proper  manner  of  treat- 
ment, no  wonder  that,  after 
elbow-fractures,  cases  of  gun- 
stock  deformity  and  j)artial 
dislocation  with  inability  to 
flex  the  elbow  are  not  at  all 
rare. 

The    author's    conviction 
is    that    in    many   instances 
exact   reposition    and   reten- 
tion are  utterly  impossible  unless  the  fragment  is  cut  down  upon  and  sut- 
ured or  nailed  to  its  original  seat.     The  insertions  of  the  muscles  of  the 
13 


Fig.  Tl. — Dressing  for  wounds  of  hand  and  forearm. 


84 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


forearm  about  the  epicondyles  must  exert  a  great  influence  upon  the  dis- 
placement of  the  fragments,  hence  it  seems  tliat  flexion  would  be  the  better 
position  to  counteract  the  tendency  to  displacement.  But  all  assertions 
made  to  that  effect,  that,  in  spite  of  the  presence  of  a  large  swelling,  reduc- 


FiG.  72. — Anterior  view  of  gun-stock  deformity  due  to  elbow  fracture. 


tion  can  always  be  accomplished  and  retention  maintained,  have  appeared 
to  the  author  as  a  hollow  pretense  or  self-deception. 

A  very  guarded  prognosis  in  elbow-fractures  is,  on  the  part  of  the  physi- 
cian, a  sign  of  wisdom  and  discretion. 

Where  very  limited  motion  and  an  unfavorable  ijosition  result  in  spite 

of  careful  treatment,  the  only  means  of 
correction  is  arthrotomy  with  subsequent 
partial  or  total  exseetion. 


Fig.  7-3. — Lateral  view  of  BernharJ 
Loebel's  elbow. 


Fig.  74.— Normal  aspect  of  lower  end  of  hume- 
rus. A  A.  Transverse  diameter,  b  b.  Line  of 
fracture.     In  Bernhard  Loebel's  case. 


Case  I. — Bernhard  Loebel,  aged  two.    October  27,  1886,  injured  bis  elbow  by  fall- 
ing off  a  chair.     The  arm  was  put  up  by  a  physician  in  tlie  flexed  position  in  plaster 


Fig.  75. — Showing  relative  positions  of  frag- 
ments in  Bernhard  Loebel's  case. 


Fig.  76. — Anterior  view  of 
lower  end  of  humerus  in 
Bernhard  Loebel's  case. 


of  Paris,  and  remained  in  this  dressing  for  a  fortnight.     Lee.  7,  1886. — The  elbow 
joint  showed  very  marked  gun-stock  deformity.     It  was  held  at  an  angle  of  about 


SPECIAL  APPLICATION  OP  THE  ASEPTIC  METHOD. 


85 


one  hundred  and  forty  degrees.  Flexion  could  be  carried  to  about  one  hundred  and 
ten  degrees;  extension  not  beyond  the  angle  first  mentioned.  The  forearm  was  dis- 
placed inward  and  backward,  and  the  tendon  of  the  triceps  described  a  well-pro- 
nounced concave  line.  An  abnormal  mass  of  bone  could  be  felt  in  the  bend  of  the 
elbow  externally,  behind  and  below  which  the  head  of  the  radius  could  be  made  out 
with  some  difficulty.  A  posterior  incision  midway  between  the  abnormal  mass  of 
bone  and  the  olecranon  opened  the  joint,  and  the  periosteum  was  raised  by  means  of 
the  knife  and  elevator  on  both  sides  of  the  incision  until  the  lower  end  of  tlie  humerus 
could  be  turned  out  for  inspection.  It  was  found  that  the  deformed  callus  consisted  of 
the  external  epicondyle,  capitellum,  and  a  small  portion  of  the  trochlea  that  had  been 
broken  off  obliquely,  and  was  tilted  and  pulled  forward  by  the  action  of  the  flexors  so 
as  to  present  its  articular  aspect  forward,  part  of  the  fractured  surface  looking  back- 
ward. In  this  position  bony  union  had  taken  place.  The  elongation  of  the  outer  half 
of  the  articular  end  of  the  humerus  accounted  for  the  gun-stock  deformity ;  the  pres- 
ence of  the  large  mass  of  bone  dis- 
placed forward  by  tilting  of  the  frag- 
ment explained  the  inability  to  flex. 
The  lower  end  of  the  humerus  was 
pared  ofl"  horizontally  with  the  knife, 
care  being  taken  to  remove  a  little 
more  from  the  external  than  from 
the  inner  half  of  the  lower  end  of 
the  humerus,  in  order  to  preserve 
the  "carrying  point."  The  capsule 
and  skin  were  united  by  suture. 
One  drainage  -  tube  was  inserted. 
The  arm  was  put  up  in  extension  in 
a  couple  of  lateral  pasteboard  splints. 
No  fever  followed.  Lee.  IJ^tTi. — First 
change  of  dressings.  In  anaasthesia 
the  tube  was  removed,  and  the  arm 
was  flexed  to  an  acute  angle  and  put 
up  in  this  position  in  two  lateral 
pasteboard  splints.  Dec.  19th. — Pas- 
sive motion  was  practiced  in  anaes- 
thesia, and  the  arm  was  fixed  in  the 
straight  position.  Dec.  23d. — Passive 
motion  without  ether.  Fixation  at 
an  acute  angle.  Dec.  29th. — Free 
passive  motion  to  normal  limits. 
Splints  abandoned  and  active  move- 
ments commenced.  March  Sd. — 
Outline  of  elbow  almost  normal. 
Flexion  and  extension  normal. 

Case  II. — Willie  H.,  aged  elev- 
en.   "Very  pronounced  gun-stock  de- 
formity due  to  fracture  of  the  elbow- 
joint  sustained  two  and  a  half  years 
ago.     The  treatment  had  been  conducted  by  a  surgeon  of  good  repute.     Flexion  could 
be  carried  to  a  right  angle,  extension  to  about  one  hundred  and  thirty  degrees.     Fig. 
77  shows  the  boy's  arm  in  full  extension.    June  17,  1887.— Avthrotomj  done  at  Mount 


Fig.  77. — Gun-stock  deformity  due  to  T-fracture  of 
the  lower  end  of  the  liumenis.     Willie  H.'s  case. 


86 


RULES  OF  ASEPTIC  AND  ANTISEPTIC   SURGERY. 


Sinai  Hospital  revealed  a  very  curious  condition  of  things.  The  hroken-oflf  external 
condyle  and  capitellum  occupied  a  position  similar  to  that  observed  in  the  preceding 
case.  The  ulna  was  dislocated  backward  and 
inward  from  the  fragment  representing  tlie  tro- 
chlea, which  was  attached  by  callus  to  the  an- 
terior aspect  of  the  lower  end  of  the  humerus. 
Apparently  a  T-shaped  fracture  of  the  lower 
end  of  the  humerus  had  taken  place.  The  ar- 
ticular surface  had  a  most  grotesque  shape.  The 
cartilaginous  surfaces  of  tlie  trochlea  and  sig- 
moid incisure  were  coated  with  a  dense  mass 
of  connective  tissue.  The  broken-off  coracoid 
process  was  attached  to  the  fragment  of  the 
trochlea.  The  articular  surface  was  pared  off 
to  approximate  the  shape  of  a  normal  hume- 
rus, jmd  the  wound  was  drained,  sutured,  and 
the  arm  put  up  in  a  pasteboard  splint.  Normal 
union  by  primary  adhesion  of  the  wound  took 
place,  but  an  annoying  complication,  consisting 
of  paralysis  of  the  forearm  and  hand,  was  noted. 
This  untoward  event  was  probably  caused  by 
the  fact  that  the  pad  of  Martin's  bandage,  used 
for  producing  artificial  anaemia,  had  been  ])laced 
over  the  inner  aspect  of  the  arm,  exerting  undue 
pressure  over  the  nerves.  June  19th. — The 
compressive  dressings  were  removed,  the  drain- 
age-tube was  withdrawn,  and  the  wound  re- 
dressed.   July  2d. — The  patient  was  discharged 

from  the  hospital  with  healed  wound.     Local      Fig.  78. — Kesult  after  exscction  of  elbow- 
♦«^„4-.,,^„*   „#  1-1  1        •  J  ioint  for  ffun-.stock  deformity.     AVillie 

treatment  oi  paralysis  by  galvanism  and  mas-         ii.'s  case 

sage  was  commenced.     July  22d. — Flexion  and 

extension  of  forearm  and  fingers  re-established.     Aug.  1st. — Function  of  elbow  be- 
coming normal.     Aug.  19th. — Muscular  power  fully  restored.     (See  Fig.  78.J 

Habitual  luxation  of  the  shoulder-joint,  a  very  annoying  and  rebellious 
complaint,  may  also  be  cured  by  artlirotomy  and  partial  exsectioD  of  the 
redundant  capsular  ligament.     (See  case  on  page  8,  Note  2.) 


V.     OPERATIONS    FOR    DEFORMITIES. 

1.  Knock-Knee  and  Bow-Leg. — Operative  exposure  of  the  medullary  tissue 
of  the  long  bones  is  a  dangerous  procedure  unless  suppuration  can  be  ex- 
cluded from  the  wound.  By  the  successful  employment  of  the  aseptic 
method  the  danger  of  osteomyelitis  can  be  virtually  excluded. 

McE wen's  osteotomy  is  one  of  the  safest  and  most  useful  procedures  of  the 
newer  surgery.    It  has  almost  entirely  displaced  purely  orthopedic  methods. 

For  knock-knee,  after  division  of  the  soft  parts  by  a  short  longitudinal 
incision,  the  cancellous  tissue  of  the  lower  end  of  the  femur  is  divided  by 
a  properly  shaped  chisel,  called  osteotome.  For  bow-leg,  the  osteal  section 
is  carried  through  the  upper  end  of  the  shaft  of  the  tibia  and  fibula,  or 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD. 


8Y 


through  the  lower  end  of  the  femur,  or  both.  The  ojDeration  is  done 
under  artificial  anaemia ;  and  the  dressings  are  applied,  and  the  limb  is  put 
up  in  a  contentive  dressing — preferably  plaster  of  Paris — before  the  removal 
of  the  constricting  elastic  band.  New-formed  bone  is  thrown  out  into  the 
gap  caused  by  the  correction  of  the  position  of  the  bones,  and  by  the  end 
of  three  or  four  weeks  firm  union  in  a  normal  position  is  the  result. 

Case. — Leopold  Heymann,  clerk,  aged  nineteen.  Very  marked  bow-legs,  the  dis- 
tance between  the  internal  condyles  of  the  femora  being  three  and  a  half  inches.  No- 
vember 15,  1883. — Double  osteotomy  of  the  tliighs  at  Mount  Sinai  Hospital.  Plaster- 
of-Paris  splints.  Dec.  l^Ti. — Change  of  dressings.  Wounds  healed  by  primary  union ; 
bones  firnily  consolidated.  The  knees  were  in  contact,  but  the  curvature  of  the  tibiae, 
which  represented  a  great  part  of  the  deformity,  was  still  very  marked.  Undoubtedly 
osteotomy  of  the  shin-bones  would  have  given  a  better  result.  The  patient  declined 
further  operative  interference. 

2.  Bony  Ancliylosis  in  a  vicious 
position. 

Case  I. — Lina  Frieberger,  aged  fif- 
teen.  Bony  anchylosis  of  right  and  pseud- 
anchylosis  of  left  maxillary  joint,  prob- 
ably due  to  acute  osteomyelitis  of  right 
ascending  ramus.     The  teeth  were  in  ab- 
solute apposition,  and  no  solid  food  could 
be  taken.     Marked  facial   hemiatrophy. 
In  childhood  a  suppurating  aflfection  of 
the   right   cheek   was   noted.     April  3, 
1886. — Exsection  by  chisel  and  mallet  of 
the  left  maxillary  joint  (hemiatrophy  of 
the    same    side). 
The  operation  did 
not    relieve    the 
functional     trou- 
ble ;     the     joint 
was  found  pseud- 
anchylosed,      the 
cartilages     gone, 
^ndthecapitellum 
nearly    absorbed. 
The  wound  healed 
by  primary  inten- 
tion.   April  29th. 
—  Exsection     of 
right      maxillary 
joint,  which  was 
found  firmly  an- 
chylosed.         The 

semilunar  incision  was  obliterated,  the  capitellum,  coronoid  process,  and  temporal  bone 
forming  one  solid  mass.  Immediately  after  its  removal  the  teeth  could  be  separated 
to  the  distance  of  an  inch  and  a  quarter.  Primary  union.  Perfect  restoration  of  func- 
iioD  noted  in  January,  1887. 


Fig.  79. — Arraneement 
of  nails  in  Maggie 
Schweizer's  case. 


Fig.  80. — Final  result  in  Maggie  Schweizer's 
case.  Cross-marks  indicate  places  where 
nails  were  driven  in.     (Page  88.) 


88 


RULES  OF  ASEPTIC  AND   ANTISEPTIC  SURGERY. 


Case  II. — Maggie  Schweizer,  aged  fifteen.  Bony  anchylosis  of  knee-joint  at  a  right 
angle,  in  consequence  of  infantile  acute  osteomyelitis  of  tibia,  with  suppuration  of  knee- 
joint.  January  22^  1S86. — At  the  German  Hospital,  excision  of  the  patella  and  of  a 
wedge-shaped  piece  of  bone,  with  preservation  of  the  epiphyseal  lines  of  femur  and 
tibia.  Transverse  cutaneous  Incision,  as  for  knee-joint  exsection.  Division  of  the 
bones  by  the  saw,  after  peeling  off  of  the  periosteum.  The  sawed  surfaces  were  brought 
together,  and  their  tixation  was  secured  by  tiiree  steel  nails,  which  were  driven  diag- 
onally through  the  tibia  and  femur  in  the  horizontal  i)lane — that  is,  from  the  lateral 
aspect  of  the  extremity.  The  locking  of  the  femur  and  tibia  was  so  firm  that  the  limb 
could  be  raised  and  handled  like  a  solid  staff.  The  application  of  the  dressings  was 
thereby  made  a  very  easy  procedure.  Full  plaster-of- Paris  splint.  No  reaction  and  no 
fever  were  observed.  Feb.  23d. — First  change  of  dressings.  The  nails  and  two  drain- 
age-tubes inserted  at  the  operation  were  removed.  The  bones  were  found  firmly 
united.  Over  a  small  aseptic  dressing  a  light  silicate-of-soda  splint  was  applied,  and 
the  patient  was  directed  to  walk  on  crutches.  March  15th. — Discharged  cured  with 
light  silicate  splint.  May  10th. — Presented  herself  to  author,  walking  excellently  with 
the  aid  of  a  raised  sole.     Shortening,  two  and  a  half  inches. 

3.  Deformed  Callus. 

Case  I. — William  Paradies,  laborer,  aged  thirty-eight.  Deformed  callus  of  the 
lower  end  of  the  tibia  following  a  supra-malleolar  fracture  of  the  leg.  Radiating  pain 
issuing  from  the  site  of  the  deformity,  due  to  pressui'e  on  the  in- 
tegument, which  was  tightly  stn'tched  over  the  protruding  edge 
of  the  upper  fragment.  March  7,  1887. — The  deformed  bone  was 
exposed  and  chiseled  away  on  a  level  with  the  surface  of  the  dis- 
tal fragment.  Suture ;  no  drainage.  Primary  union.  March  21st. 
— Patient  discharged  cured  from  the  German  Hospital. 

Case  II. — Ernst  Langer,  carpenter,  aged  forty-five.  Deformed 
callus  of  fibula.  Angust  29,  1885. — At  the  German  Hospital,  in- 
cision and  exsection  of  the  callus  by  chisel  and  mallet.  Apposi- 
tion and  fixation  of  the  fragments  by  a  strong  catgut  bone-suture. 
Primary  union.  Discharged  cured,  September  26,  1885,  with  firm 
consohdation. 

4.  Club-Foot  and  Pes  Valgus. — On  account  of  its  sim-  Fig.  si.— Deformed 
plicity  and  the  excellent  results  reported  both  from  er  end  of  tibia, 
abroad  and  at  home  after  its  practice,  Phelps's  operation  diel/^'"  ^'^'^^ 
seems  to  deserve  extended  trial.  It  consists  in  the  com- 
bination of  tenotomy  of  the  tendo  Achillis  with  a  free  division  of  all  the 
soft  tissues  situated  on  the  mesial  side  of  the  planta  pedis,  the  incision 
penetrating  down  to  the  bone  and,  if  necessary,  into  joints.  The  idea  of 
dividing  all  resisting  tissues  underlies  the  plan  of  procedure.  The  incis- 
ion includes  the  tendons  of  the  tibialis  jiosticus,  flexor  digitorum  communis 
longus,  the  belly  of  the  flexor  digitorum  brevis,  of  the  abductor  hallucis, 
the  plantar  fascia,  the  long  plantar  ligament,  the  deltoid  ligament,  the 
nerves,  and,  if  unavoidable,  the  vessels.  The  incision  need  not  be  a  very 
long  one.  It  commences  just  in  front  of  the  tip  of  the  inner  malleolus, 
and  extends  downward,  according  to  the  age  of  the  patient,  for  about 
an  inch. 

All  the  parts  named  above  can  be  easily  reached  from  the  wound  with 


SPECIAL  APPLICATION   OF   THE   ASEPTIC   METHOD. 


89 


a  tenotomy  knife,  unless  they  are  in  the  direct  line  of  section,  when  they 
are  divided  with  the  scalpel.  Preservation  of  the  integrity  of  the  plantar 
artery  is  very  desirable,  on  account  of  the  avoidance  of  saturation  of  the 


Pig.  82. — Group  illustrating  an  operation  about  the  foot  or  ankle. 

dressings  with  blood.     The  operation  being  done  with  the  aid  of  Esmarch's 
band,  all  the  tissues  can  be  readily  identified  as  they  are  gradually  ex- 
posed step  by  stejD.      The  internal  plantar  artery  can  thus  be  seen  and 
doubly  tied.     The  main  trunk  of  the  artery  sweeps 
in  a  long  curve  outward  to  the  external  side  of  the 
sole,  and  is  out  of  the  line  of  section.      Should  it 
be  divided  accidentally,  and  the  blood  soil  the  dress- 
ings at  once,   it   is  proper  to  remove  them,  to  re- 
apply Esmarch's  band,  to  enlarge 
the  incision,  and  to  find  and  deli- 
gate  the   cut  ends  of  the  vessel. 
In  extreme  cases  of  adults,  where 
the   bones    have    acquired    a  defi- 
nitely vicious   shape,    linear  oste- 
otomy of  the  neck  of  the  asti'aga- 
lus   must   be  added    to    the   teno- 
myotomy performed  in  the  planta. 

The     author    was     surprised     to         Fig.  83.— Dressing  tor  wounds  of  ankle  and  toot. 

see  the  ease  with  which  even  great 

deformities  conld  be  corrected  after  the  division  of  all  tissues  mentioned 
above.  Of  course,  the  wound  is  a  wide  gap,  which  is  widened  still  more 
by  the  corrected  position.     Its  healing  is  accomplished  by  the  "organi- 


90 


RULES  OF  ASEPTIC   AND  ANTISEPTIC  SURGERY. 


zation  of  the  moist  blood-clot"  (Schede's  method).  As  soon  as  the  wound 
lias  been  well  cleansed  by  irrigation,  a  piece  of  rubber  tissue,  previously 
kept  immersed  in  a  five-per-cent  solution  of  carbolic  acid  for  twenty- 
four  hours,  is  placed  over  the  gap.  This  is  covered  with  a  few  strips  of 
iodoform  gauze  and  an  ample  dressing  of  sublimated  gauze.  While  the 
foot  is  held 
in  the  cor- 
rect position 
by  an  assist- 
ant, the  sur- 
geon applies 
over  the  asep- 
tic dressing 
a  plaster-of- 
Paris  splint. 
While  the 
plaster  is  setting, 
held  with  force 
overcorrected 


Fig. 
Elevation  of  the  feet 
after  Phelps's  operation. 


the  foot  is 
in  a  somewhat 
position,  which 
will  allow  for  the  slight  giving 
way  of  the  aseptic  dressing. 
Then  Esmarch's  band  is  re- 
moved, and  the  feet  are  held 
in  the  vertical  posture  for  an 

hour  or  two  after  the  operation.     After  disappearance  of  passive  hyper- 
jemia  they  are  placed  on  a  pillow  in  the  horizontal  posture. 

In  a  fortnight  or  so  the  plaster  of  Paris  is  cut  away,  and  a  silicate  splint 
is  apjilied.  As  soon  as  it  is  dry  the  patient  is  allowed  to  walk  with  the  aid 
of  crutches.  In  about  four  weeks  after  the  operation  the  silicate  shoe  is 
split  on  top,  and  the  dressings  are  removed.  In  many  cases  the  wound 
will  be  found  cicatrized  over  by  this  time.  Should  this  not  be  the  case, 
however,  the  aseptic  dressing  and  silicate  shoe  must  be  reapplied.  When 
the  wound  is  perfectly  healed,  the  silicate  splint  can  be  replaced  by  a  well- 
fitting  laced  shoe. 

Note. — The  silicate  shoe  must  not  include  more  than  about  one  third  of  the  leg,  in  order 
not  to  prevent  treatment  of  its  debilitated  muscles  by  massage  and  electricity. 

The  fear  that  the  severed  tissues  will  not  grow  together  properly  is 
unfounded.  Schede  had  the  opportunity  of  ascertaining  by  autopsy  the 
exact  re-establishment  of  the  physiological  relations  of  the  cut  tissues. 
The  best  proof  of  the  fact  is,  however,  the  restoration  of  the  function  of 
the  cut  parts. 

The  results  exhibited  by  Phelps  at  a  meeting  of  the  New  York  State 
Medical  Society  at  Albany  were  so  excellent  as  to  deserve  the  utmost  atten- 
tion. They  surpassed  everything  the  author  has  seen  accomplished  for 
the  cure  of  this  deform  it  v. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC   METHOD. 


91 


Case. — Harry  Epstein,  school-boy,  aged  twelve,  suffering  from  chronic  interstitial 
nephritis  as  a  consequence  of  scarlatina.  General  condition  poor,  on  account  of  lack 
of  exercise,  due  to  disability  from  club-feet.     The  patient  was  walking  on  the  outer 

edge  of  the  plantse.  The 
urine  contained  granular 
and  hyaline  casts,  and 
twenty  per  cent  of  albu- 
men. March,  IJf.^  1887. — 
At  Mount  Sinai  Hospital, 
douljle  Phelps's  operation 
was  done  under  chloro- 
form, which  was  borne 
excellently,  the  operation 
lasting  forty-five  minutes. 
No  fever,  no  reaction 
followed.  March  28th.— 
The  plaster  shell  was  cut 
away,  and  the  patient 
commenced  to  hobble 
about  in  the  ward  on 
crutches.  April  10th. — 
The  old  water-glass  splints 
were  removed,  and  were 
replaced  by  a  new  set, 
which  were  worn  until 
June.     After  this  the  patient  was  fitted  with  a  pair  of  lacing  shoes. 

Case  II. — Aaron  Meyer,  oysterraan,  aged  twenty-nine,  far  gone  and  very  painful 
pes  valgus  of  both  feet.  Oct.  12,  1885.— At  Mount  Sinai  Hospital,  exsection  of  a  bony 
wedge  by  chisel  and  mallet  from  the  internal  aspect  of  the  head  of  the  astragalus, 
the  scaphoid,  and  calcaneum  of  the  right  foot.  Area  of  the  base  of  the  wedge  about 
one  square  inch.  The  remnants  of  the  neck  of  the  astragalus  and  calcaneum  were 
divided  entirely  by  the  osteotome,  and  the  foot  was  broken  into  shape  by  manual  force 
and  put  up  in  an  aseptic  dressing  and  plaster-of-Paris  splint.  JVov.  1st. — Dressings 
removed,  wound  presenting  a  strip  of  shallow  granulations,  Dec.  1st. — Discharged 
cured.  Feb.  1st. — Foulis's  operation  on  the  left  foot,  which  showed  a  lesser  degree  of 
deformity  than  the  right  foot  before  operation.  The  talo-navicular  joint  was  incised, 
and  its  entire  cartilaginous  covering  was  removed  by  scraping  with  a  scoop.  Fe^.  21st. 
—First  change  of  dressings ;  primary  union.  Fel.  27th. — Patient  discharged  cured. 
In  March,  1887,  patient  presented  himself  for  examination.  Firm  anchylosis  of  the 
talo-navicular  joints  of  both  sides,  and  very  good  function  had  been  secured,  the 
j)atient  attending  to  his  accustomed  business. 


Fig.  85. — Appearance  of  wounds  four  weeks  after  Phelps's 
operation.     Harry  Epstein's  case. 


VI.     PLASTIC    OPERATIONS. 

Aseptics  have  greatly  improved  the  results  of  plastic  operations,  and 
especially  erysipelas  has  been  almost  entirely  banished  from  facial  wounds 
made  for  plastic  purposes.  In  performing  any  operation  about  the  face  it 
is  necessary  for  the  surgeon  to  protect  himself  and  the  patient  from  two 
sources  of  infection.  One  is  the  oral  and  nasal  secretions,  the  other  the 
patient's  head,  notably  his  hair.  The  latter  should  always  be  enveloped  in 
14 


92 


EULES   OF   ASEPTIC   AND  ANTISEPTIC   SURGERY. 


a  cap  extemporized  from  a  good-sized  towel  or  compress  wrung  out  of  cor- 
rosive-sublimate lotion.  The  accompanying  illustrations  show  the  manner 
of  folding  the  towel  about  the  head.     It  should  be  firmly  fastened  by  a 

narrow  roller-bandage  encircling  the  forehead 
and  occiput.  Whenever  vomiting  occurs,  a 
careful  cleansing  of  the  soiled  skin  and  a 
cliange  of  towels  are  indicated. 

Where  there  is  no  great  tension  to  be  over- 
come, tine  catgut  (No.  0)  makes  excellent  sut- 
uring material  for  facial  wounds  after  plastic 
operations. 

Where  the  tension  is  great  (which,  how- 
ever, should  be  reduced  to  a  minimum  by  the 

proper  shaping  of 
flaps  and  free  dis- 
section), silver  wire, 
or  silkworm  -  gut 
well  soaked  in  car- 
bolic lotion,  will  be 
well  employed  for 
retentive  purposes. 
Sutures  of  coapta- 
tion are  best  made 
with  fine  catgut. 

Hare  -  lip    pins 
were  never  used  by 
the  author,  as  they  are  unnecessary,  and  offer  no  advantages  over  the  sutur- 
ing material  more  generally  employed  by  surgeons. 

Where  the  wounded  surfaces  can  be  completely  closed  by  suture,  no 
dressings  whatever  are  needed.  A  thick  layer  of  iodoform  dusted  over  the 
line  of  union  will  soon  unite 
with  the  oozings  into  a  paste, 
which  on  becoming  dry  will 
form  an  excellent  and  un- 
irritating  protection  to  the 
wounds  and  suture-points. 
Daubs  of  collodion,  or  the 
application,  after  hare  -  lip 
operations,  of  strips  of  ad- 
hesive plaster  to  the  face, 
are  especially  unpleasant  and 
irritating  to  infants.  They 
create  uneasiness,  and  excite 
the  little  patients  into  crying  fits,  and  the  distortion  of  the  face  resulting 
from  frequent  crying  is  certainly  not  conducive  to  the  uninterrupted  rest 
and  union  of  the  wounds. 


Applvinsj  aseptic  cap. 


step. 


'Vppl^'iug  aseptic  cap.     Second  step. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD. 


93 


Fig.  88. — Aseptic  cap  in  situ.     Caueer  of  lip, 


Eetentive  sutures  should  never  be  removed  too  soon — that  is,  before  the 
seventh  day.     The  smaller  catgut  sutures  vs^ill  be  absorbed  by  that  time. 

Where  an  uncovered  de- 
fect is  unavoidably  left  be- 
hind, on  account  of  lack  of 
integument  or  some  other 
reason,  Schede's  procedure  is 
the  best  means  of  preventing 
supj)uration.  A  strip  of  rub- 
ber tissue  is  laid  over  the  de- 
fect, and  is  suitably  inclosed 
in  an  aseptic  dressing.  The 
blood-clot,  which  will  form 
under  the  rubber  tissue,  will, 
if  it  be  well  protected  from 
desiccation  and  decomposi- 
tion, rapidly  become  organ- 
ized. 
In  plastic  operations  performed  alout  the  soft  and  hard  palate  the  con- 
dition of  the  teeth  should  be  well  attended  to  previous  to  the  undertaking. 
Decaying  teeth  should  be  removed,  and  an  unwholesome  state  of  the  gums 
and  mucous  membrane  should  be 
corrected  by  the  diligent  use  of  the 
tooth-brush  and  a  1:1,000  solution 
of  permanganate  of  potash  as  a 
mouth-wash. 

Urethroplasty  will  fail  almost  in- 
variably if  ammoniacal  urine  is  per- 
mitted to  pass  over  the  line  of  union. 
Acid  urine  is  not  deleterious  to  the 
wounds.  Where  chemical  examina- 
tion has  established  the  presence  of 
ammoniacal  decomposition  of  the 
urine,  frequent  washings  of  the  blad- 
der and  the  urethra  with  weak  so- 
lutions of  permanganate  of  potash 
(1 :  4,000  or  5,000)  and  the  internal 
administration  of  boracic  acid  will 
suitably  prepare  those  organs  for  the 
operation.  To  prevent  the  soiling 
of  the  wound  by  ammoniacal  urine, 
a  soft  Nelaton  catheter  should  be 
passed  into  the  bladder  and  fixed  by 

a  proper  bandage  to  prevent  its  escape.  Daily  antiseptic  irrigation  of  the 
bladder  should  be  continued  all  the  time  while  permanent  catheterism  is 
used.     As  soon  as  the  wound  is  firmly  united,  catheterism  may  be  stopped. 


Fig.  89. — Dressing  for  excision  of  the 
upper  jaw. 


94 


RULES  OF  ASEPTIC   AND   ANTISEPTIC  SURGERY. 


Perineal  plastic  operations  on  tb,e  female  require  a  previous  tlioroiifrb 
disinfection  of  tlie  vulva  and  vagina  by  mercurial  irrigation,  which  should 
be  kept  up  during  the  entire  time  of  the  operation.  Here,  too,  dressings 
are  annoying  and  unnecessary.  Catheterism,  temporary  confinement  of  the 
bowels,  and  frequent  irrigation,  with  subsequent  dusting  with  iodoform 
powder,  will  afford  all  the  security  needed  against  infection. 

Aside  from  the  care  for  the  production  and  maintenance  of  the  aseptic 
condition  during  and  after  the  operation,  another  important  requirement 
must  be  fulfilled.  This  is  a  thorough  and  complete  appositioji  of  the  entirety 
of  the  wounded  surfaces  hy  several  tiers  of  catgut  sutures,  and  a  correct 
union  of  the  mucous  membranes  of  the  vagina,  and  of  the  rectum  if  necessary. 
A  slovenly  manner  of  suturing  will  lead  to  the  formation  of  hollow  spaces, 
which  will  become  filled  by  blood-clot :  and,  if  the  sutures  of  the  mucous 
membranes  be  also  inexact,  contact  of  the  vaginal  or  rectal  discharges  with 
the  unprotected  clot  will  lead  to  its  inevitable  putrescence,  and  to  partial 
or  general  suppuration.  An  exact,  deep  and  superficial  suture  is  the  best 
protection  of  perineal  operative  wounds  against  infection. 

Note. — The  stitclies  holding  the  mucous  membrane  together  should  never  pass  through  the 
epithelium.  They  should  be  entered  and  brought  out  just  below  the  epithelial  lining.  This 
will  prevent  inversion  of  the  edges,  and  the  stitch-holes  will  be  also  protected  from  infection  by 
the  ridge  of  protruding  mucous  membrane. 

On  account  of  the  great  vascularity  of  the  face,  facial  wounds  will  often 
heal  without  sujapuration,  even  if  very  indifferent  asepticism  was  observed. 

Xot  so  in  other  parts  of  the  body,  notably  about  the  extremities,  whej-e 
suppuration  is  much  more  easily  produced,  and  is  generally  followed  by 
sloughing  of  the  flaps.  Strict  asepticism,  avoidance  of  tension  by  sutures 
and  of  pressure  by  dressings,  are  imperative  conditions  of  success  in  plastic 
operations  done  on  the  extremities. 


Fig.  90. — Maas's  operation.     Primary  plaster-of-Paris  dressiusr*.     On  the  right  leg,  the  defect 
to  be  covered ;   on  the  left  leg,  flap  deiacheJ  from  calf. " 


Case  I. — Abraham  Strecker,  aged  seven.  Circular,  extensive  skin  defect  of  the 
right  leg,  due  to  old  compound  fracture;  extensive  ulceration  of  frontal  part  of  the 
cicatrix ;  oedema  of  the  foot,  caused  by   contraction  of  the  circular  cicatrix.     Dec.  7, 


SPECIAL   APPLICATION   OF   THE   ASEPTIC   METHOD. 


95 


1885. — At  Mount  Sinai  Hospital,  plastic  repair  of  the  frontal  part  of  the  defect  by  Maas's 
procedure.  Each  thigh  and  foot  was  first  incased  in  a  plaster-of- Paris  splint,  then  the 
cicatrix  was  disinfected  with  an  eight-per-cent  solution  of  chloride  of  zinc  and  pared  oflE 


¥m.  yl. — Alaas' 


operation,     t^econdary   plaster-of-Paris   dressings  fixing  relative  position   of 
extremities.     Flap  attached  to  its  new  habitat. 


with  the  scalpel.  After  this  a  properly  shaped,  generous  skin-flap  was  raised  from  the 
posterior  aspect  of  the  left  leg.  Now  the  extremities  were  superimposed  in  such  a  manner 
as  to  bring  the  flap  over  the  vivifled  surface  of  the  right  leg,  wherewith  it  was  brought 

in  contact  on  its  raw  surface.  A  second- 
ary plaster-of-Paris  dressing  applied  over 
the  primary  plaster  splints  secured  the 
limbs  and  the  flap  in  their  new  relative 
position.  The  exposed  raw  surface  of  the 
pedicle  of  the  flap  was  wrapped  in  an 
envelope  of  rubber  tissue  to  prevent  its 
desiccation ;  the  flap  was  lightly  attached 
to  its  new  habitat  by  a  few  catgut  sut- 
ures. The  edges  of  the  flap  were  dust- 
ed with  iodoform,  and  the  defect  of  the 
calf  was  inclosed  in  an  aseptic  dressing. 
With  the  exception  of  a  small  portion 
of  the  end  of  the  flap  which  necrosed, 
primary  union  throughout  was  achieved. 
Dec.  21st. — The  pedicle  of  the  flap  was 
cut,  and  the  limbs  were  released  from 
their  confinement.  Rapid  cicatrization 
of  the  remnant  of  the  original  and  of  the 
defect  of  the  calf  followed,  and,  January 
30,  1886,  the  boy  was  discharged  cured. 
The  oedema  of  the  foot  had  disappeared. 
Case  II. — Adolph  Carstens,  school- 
boy, aged  eleven.  Feb.  17,  1887.— At 
the  German  Hospital,  Maas's  operation 
for  a  large  skin  defect  of  the  anterior 
aspect  of  the  tibia,  due  to  severe  traumatism.  The  case  was  managed  exactly  like  the 
foregoing  one,  with  this  additional  circumstance,  however,  that  it  became  necessary 
to  pare  off  an  area  of  tlie  anterior  aspect  of  the  tibia  by  chiseling,  corresponding  to 


Fifi.  92. — Maas's  op- 
eration, final  result. 
CieatrLx  is  marked 
"with  ink. 


Fig.  93. — View  of  ci- 
catrix of  the  place 
whence  the  skin-flap 
was  taken. 


96  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

the  size  of  the  flap,  in  order  to  remove  the  condensed  cicatricial  tissue  underlying  the 
extensive  elevated  ulcer.  Thus,  a  -well-vascularized  hase  was  secured  for  the  skin-flap. 
March  ScZ.— The  pedicle  was  divided,  and,  April  10th,  the  patient  was  discharged  cured. 

VII.     ASEPTICS    OF    THE    ORAL    CAVITY. 

Long  after  the  principles  of  the  aseptic  treatment  of  external  wounds 
had  become  recognized,  the  proper  management  of  the  wounds  of  the  nor- 
mal openings  of  the  respiratory,  digestory,  and  uro-genital  tracts  was  still  a 
mooted  question.  It  was  a  comparatively  easy  thing  to  produce  in  these 
regions  an  aseptic  condition  for  the  time  of  the  operation.  But  how  to 
protect  the  wounds  from  the  inevitable  soiling  by  the  continuous  discharges 
pertaining  to  these  several  apertures,  was  first  shown  by  Billroth,  who  suc- 
cessfully employed  iodoform  as  an  effective  preventive  of  putrefaction  in 
the  oral  cavity. 

If  a  fresh  wound  of  the  oral  cavity  is  rubbed  off  with  iodoform  powder 
and  packed  with  gauze  saturated  with  iodoform,  this  dressing  will  become 
matted  together  with  the  tissues  of  the  raw  surface,  and  will  form  an 
effective  protection  against  infection  by  septic  influences.  The  secretions 
will  innocuously  pass  over  the  surface  of  the  gauze,  and  the  penetration  of 
active  germs  to  the  wound  will  be  prevented  by  the  air-tight  and  closely 
adherent  packing. 

The  course  of  oral  wounds  treated  in  this  manner  differs  widely  from  that 
observed  under  other  forms  of  treatment.  Diphtheritic  and  phlegmonous 
processes,  formerly  so  common  in  wounds  freely  communicating  with  the 
mouth,  have  become  things  of  great  rarity.  The  terrible  odor  which  could 
not  be  kept  down  by  however  frequent  irrigations  with  any  kind  of  deodor- 
izing lotion  until  the  necrosed  layer  of  tissues  was  cast  off,  is  now  generally 
absent.  By  the  time  that  the  packing  of  iodoformed  gauze  becomes  loose, 
healthy  and  vigorous  granulations  will  have  sprung  up,  and  the  wound  will 
progress  toward  uninterrupted  healing  without  pain  and  without  fever. 

As  long  as  the  packing  is  firmly  adherent,  it  should  not  be  disturbed. 
Its  forcible  extraction  would  certainly  cause  a  good  deal  of  pain,  and  would 
be  followed  by  hremorrhage  and  inflammation.  The  superficial  layers  of 
iodoformed  gauze,  becoming  soiled  by  secretions  or  food,  can  be  daily 
renewed. 

Another  important  point  to  be  observed  in  operations  about  the  oral 
cavity  is  the  control  of  haemorrhage.  The  abundant  blood-supply  of  this 
region  is  apt  to  be  the  source  of  copious  haemorrhage,  dangerous  in  itself, 
but  especially  perilous  on  account  of  the  possibility  of  the  entrance  of  blood 
into  the  air-passages. 

This  accident  may,  on  the  one  hand,  cause  instant  death  from  suffoca- 
tion ;  on  the  other,  it  may  produce  catarrhal  or  sejitic  pneumonia  by  decom- 
position within  the  bronchi. 

Haemorrhage  from  oral  wounds  can  be  controlled  in  two  ways.  They 
may  be  employed  separately  or  combined. 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.  97 


Fig.  94. — The  author's  tracheal  tampon  canniila. 


The  first  one  is  by  preliminary  ligature  of  one  or  both  lingual  arteries  ; 
the  second,  by  the  exclusive  use  of  the  actual  cautery  and  galvano-caustic 
wire  loop. 

Where  the  operation  must  needs  extend  to  the  floor  of  the  mouth,  deli- 
gation  of  the  lingual  arteries  will  be  insufficient,  and  the  use  of  the  actual 
cautery  point  or  loop  often  impracticable.  In  such  a  case,  preliminary 
tracheotomy  and  the  employment  of  a  tampon  cannula  will  be  the  only  safe 

means  of  preventing 


the  entrance  of  blood 
into  the  bronchi. 

Although  White- 
head's speculum  is  an 
excellent  instrument 
to  render  the  oral  cav- 
ity accessible,  yet  it 
will  be  unsatisfactory 
in  operations  to  be 
done  on  the  floor  of 
the  mouth.  Here  sec- 
tion or  even  partial 
excision  of  the  lower 
jaw  may  be  unavoidably  necessary  to  afford  ample  space  for  complete  excis- 
ion of  a  malignant  tumor,  and  to  make  accurate  hsemostasis  practicable. 

Where  most  or  all  attachments  of  the  tongue  to  the  inferior  maxilla  must 
be  severed,  a  strong  loop  of  silk  should  be  drawn  through  the  stump  of  the 
tongue  near  the  epiglottis,  to  be  brought  out  by  the  mouth  and  attached 
by  a  strip  of  adhesive  plaster  to  the  cheek.  This  precaution  will  enable  the 
nurse  or  attendant  to  instantly  clear  the  epiglottis  should  the  stump  of  the 
tongue  ever  slip  back  upon  and  occlude  the  entrance  to  the  larynx. 

In  the  more  extensive  cases  of  oral  surgery,  especially  after  removal  of 
the  tongue,  nutrition  will  have  to  be  carried  on  for  some  time  by  the  stom- 
ach-tube, which  can  be  left  in  for  several  days,  or  can  be  daily  introduced 
by  the  mouth  or  nostril. 

Early  operations  for  cancer  of  the  tongue  will  give  better  results  in  every 
way  than  late  ones.  But  even  of  the  latter  it  can  be  said  that,  as  a  rule, 
the  patient's  life  will  be  prolonged  by  them,  and  will  be  made  more  tol- 
erable. 

Every  oral  operation  should  be  preceded  by  a  careful  preparation  of  the 
mouth  by  extraction  of  carious  teeth  and  frequent  washings  with  a  germi- 
cide lotion,  preferably  a  1  :  1,000  solution  of  permanganate  of  potash.  Pres- 
ent stomatitis  should  be  first  got  rid  of  by  all  means. 

Case  I. — Mr.  David  S.,  wholesale  butcher,  aged  fifty-four.  Strong  smoker.  On  the 
inner  aspect  of  the  right  cheek,  opposite  a  carious  and  sharp-edged  molar,  where  an 
opaline  mucous  patch  had  existed  for  some  time,  an  elevated  ulcer  of  the  size  of  a 
silver  dollar  had  estabhshed  itself,  and  was  steadily  extending.  The  submaxillary 
lymphatic  glands  were  intumescent.    April  30^  I884. — Extirpation  of  the  growth  from 


98  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

a  transverse  incision  extending  backward  from  the  angle  of  the  mouth.  The  outer 
skin  was  saved  and  brought  together  by  a  line  of  stitches.  The  intumescent  submax- 
illary glands  were  also  removed.  Uninterrupted  recovery  followed,  but  a  small  fistula 
remained  behind,  corresponding  to  the  middle  of  the  incision  of  the  cheek,  which,  how- 
ever, closed  after  a  few  applications  of  the  thermo-cautery.  The  contraction  of  the 
cheek  was  successfully  overcome  by  the  insertion  and  wearing  of  wooden  wedges,  which 
were  abandoned  in  the  fall  of  1884.  During  the  summer  a  relapse  of  cancer  had 
developed  in  the  deep-seated  submaxillary  glands  of  the  right  side  and  in  the  submen- 
tal gland.  September  25,  I884. — The  glandular  swellings  were  extirpated  from  both 
mentioned  regions.  The  complete  removal  of  the  submaxillary  glands  necessitated 
excision  of  two  inches  of  the  deep  jugular  vein.  The  wound  healed  by  the  first  inten- 
tion; the  patient  took  his  first  walk  twelve  days  after  the  operation.  He  remained 
free  from  the  disease  until  September,  1885,  when  a  rather  rapid  swelling  of  the  sub- 
maxillary glands  of  the  left  side  was  observed.  Apparently  the  infection  had  extended 
to  the  opposite  side  of  the  neck  by  way  of  the  diseased  submental  gland.  The  original 
site  of  the  epithelioma  in  the  cheek  remained  intact  by  relapse.  October  22,  1885. — An 
attempt  was  made  to  remove  the  glandular  swelling  of  the  left  side  of  the  cheek,  but 
it  had  to  be  abandoned  on  account  of  the  W'ide  extension  and  infiltrating  character  of 
the  new  growth.  January  31,  1886. — Patient  died  of  extension  of  the  disease  to  the 
cerebrum. 

Had  the  first  oj^eration  been  undertaken  at  an  earlier  date,  the  respite 
secured  to  the  patient  would  have  been  much  longer. 

Case  II. — Katie  Jobs,  aged  thirteen.  Mucous  cyst  of  the  left  under  side  of  the 
tongue,  deeply  imbedded  in  the  lingual  tissues,  and  extending  back  to  the  hyoid  bone. 
March  24,  1883. — Deligation  of  the  left  lingual  artery  from  an  external  incision  above 
the  hyoid  bone.  Whitehead's  speculum  being  inserted,  the  tongue  was  transfixed  and 
secured  by  a  strong  fillet  of  silk.  By  this  it  was  withdrawn,  and  the  cyst  "was  easily 
extirpated  from  its  bed  by  means  of  scissors  and  forceps.  Care  was  taken  not  to  grasp 
the  cyst  with  the  mouse-tooth  forceps,  which  served  only  to  hold  aside  the  muscular 
tissue  of  the  tongue.  Minimal  haemorrhage  was  observed.  The  wound  was  stitched 
with  fine  silk  throughout  its  entire  length,  a  few  threads  of  catgut  being  inserted  into 
its  upper  corner  for  drainage.  Botli  wounds  healed  by  primary  union,  and,  April  7th, 
the  patient  was  discharged  cured  from  the  German  Hospital. 

Case  III. — Adolph  Bottger,  cooper,  aged  forty-two,  a  strenuous  smoker  and  hard 
drinker,  had  contracted  an  epithelioma  of  the  right  anterior  margin  of  the  tongue,  ex- 
tending well  forward  to  the  gums  of  the  canine  tooth,  and  involving  the  intervening 
part  of  the  floor  of  the  mouth.  No  intumescence  of  the  lymphatic  glands  could  be 
made  out.  August  28,  1883. — At  the  German  Hospital  the  right  lingual  artery  -was 
deligated,  and  the  right  half  of  the  tongue  was  excised  by  the  aid  of  forceps  and  scis- 
sors. A  morphine  injection  had  been  administered  before  the  operation,  and  anaes- 
thesia by  chlorofoi-m  was  not  carried  to  insensibility.  Haemorrhage  was  very  moder- 
ate. In  excising  the  floor  of  the  mouth  the  bleeding  was  somewhat  profuse,  and  a 
large  number  of  spurting  vessels  had  to  be  tied.  The  resulting  wound  was  packed 
with  iodoforraized  gauze.  No  fever  or  inflammation  followed,  and  the  power  of  deglu- 
tition was  re-established  on  the  third  day.  The  patient  left  the  bed  on  September  9th, 
and  October  9th  was  discharged  cured.  In  February,  1884,  the  disease  returned  on 
the  inner  aspect  of  the  gums.  March  10th. — Three  inches  of  the  alveolar  process  of 
the  horizontal  part  of  the  lower  maxilla  were  excised,  together  with  the  entire  cicatrix. 
Cure  was  delayed  by  necrosis  of  the  remaining  portion  of  the  body  of  the  jaw.  April 
SOth. — The  sequestrum  was  extracted.     May  20,  I884. — Patient  was  discharged  cured. 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.  99 

May  17,  1886. — The  patient  returned  with  a  far-gone  relapse,  starting  from  the  left 
submaxillary  stump.  May  19th. — Exsection  was  performed.  Violent  delirium  tremens 
set  in  immediately  after  the  operation,  followed  by  death  in  collapse. 

Case  IV. — Fritz  Osterwald,  shoemaker,  aged  sixty-three ;  strong  smoker ;  cancer 
of  the  right  margin  of  the  tongue  well  back  near  the  anterior  pillar  of  the  fauces,  with 
considerable  involvement  of  the  floor  of  the  mouth.  February  2,  1886. — Deligation 
of  the  left  lingual  artery,  followed  by  excision  of  the  corresponding  half  of  the  tongue 
and  floor  of  the  mouth  in  morphine-chloroform  ansesthesia  at  the  German  Hospital. 
Access  was  gained  to  the  oral  cavity  by  a  semicircular  incision  following  the  under 
side  of  the  lower  jaw,  from  which  the  attachments  of  the  muscles  were  raised  together 
with  the  periosteum.  The  mucous  menabrane  was  cut  through,  whereupon  the  tongue 
and  floor  of  the  month  could  be  drawn  out  from  under  the  maxilla  and  turned  out  upon 
the  front  of  the  neck.  Haemorrhage  was  rather  free  in  spite  of  the  preliminary  liga- 
ture of  the  lingual  artery  ;  and,  though  the  patient  was  not  fully  angesthetized,  alarm- 
ing asphyxia  suddenly  took  place,  apparently  due  to  the  occlusion  of  the  glottis  by  a 
blood-clot.  Efforts  to  dislodge  this  were  unsuccessful,  therefore  hasty  tracheotomy 
had  to  be  performed,  resulting  in  re-establishment  of  respiration.  After  this  the  excis- 
ion was  completed  without  further  mishap.  More  than  half  of  the  tongue  was  re- 
moved up  to  the  epiglottis,  together  with  the  left  side  of  the  floor  of  the  mouth  and 
the  anterior  faucial  pillar.  The  wound  was  packed  with  iodoformized  gauze.  Nutrition 
was  carried  on  by  stomach-tube.  No  fever  followed,  but,  February  15th,  symptoms  of 
iodoform  mania  necessitated  the  removal  of  the  original  packing,  which  was  replaced 
by  corrosive-sublimate  gauze.  Feb.  18th. — The  restless  patient  was  taken  to  his  home, 
whence  he  was  transferred  to  Bellevue  Hospital,  where  he  died  a  maniac  on  February 
28th. 

The  foregoing  case  illustrates  the  dangers  from  the  entrance  of  blood 
into  the  larynx,  and  the  gi'eatest  drawback  of  iodoform  when  used  on  elderly 
individuals — namely,  its  tendency  to  produce  acute  mania.  From  this 
instance  the  author  learned  the  lesson  of  never  risking  a  rather  bloody  opera- 
tion in  the  oral  cavity  without  preliminary  tracheotomy  and  the  use  of  a 
tampon  cannula.  The  anxious  moments  spent  in  opening  the  suffocating 
patient's  trachea  will  never  be  forgotten. 

Case  V. — Victor  Jeggi,  silk- weaver,  aged  fifty-three,  a  very  moderate  smoker, 
admitted  August  20,  1885,  to  the  German  Hospital  with  lingual  cancer,  involving  nearly 
one  half  and  principally  the  right  side  of  the  tongue.  No  glandular  swelling.  Atig. 
22,  1885. — Both  lingual  arteries  were  deligated,  and  two  thirds  of  the  entire  length 
and  width  of  the  organ  were  excised  with  very  little  haemorrhage  in  mixed  (morphine- 
chloroform)  anaesthesia.  The  wound  was  packed  with  iodoformed  gauze.  Deglutition 
returned  on  August  28th.  The  wound  healed  very  rapidly,  so  that,  September  5th, 
patient  could  be  discharged  nearly  cured.  He  presented  himself,  February  21,  1886, 
with  a  relapse  in  the  floor  of  the  mouth,  but  delayed  operation  until  March  30th,  when 
the  disease  had  assumed  formidable  proportions.  Preliminary  tracheotomy  being  done, 
the  author's  tampon  canula  was  inserted.  The  middle  portion  of  the  lower  jaw  was 
excised,  and  the  remnant  of  the  tongue  was  removed  together  with  the  entire  floor  of 
the  mouth  by  means  of  the  tbermo-caustic  knife.  The  stumps  of  the  severed  arteries 
did  not  retract  (atheromatosis),  and  were  successively  tied.  The  wound  was  packed 
with  iodoformized  gauze,  and  nutrition  was  carried  on  by  the  stomach-tube.  April 
2d. — The  patient  vomited,  and  undoubtedly  some  of  the  ejecta  found  their  way  into 
the  bronchi.  April  3d. — Catarrhal  pneumonia  set  in  with  a  chill  and  a  temperature 
15 


100  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

of  104°  Fahr.  April  6th. — The  critical  condition  changed  for  the  better,  and  by  April 
15tb  the  patient  left  the  bed.  To  avoid  vomiting  produced  by  the  frequent  introduc- 
tion of  the  stomach-tube,  this  was  carried  in  through  the  nostril  and  left  in  situ  with 
evident  comfort  to  the  patient.  The  wound  contracted  rapidly,  but  in  the  middle  of 
May  relapse  appeared  in  the  pharynx,  which  ended  the  patient's  existence  in  June,  1886. 

The  presence  of  the  tampon  cannula  in  the  trachea,  effectually  shutting 
off  the  possibility  of  the  entrance  of  blood  into  the  air-passages,  made  this 
otherwise  very  bloody  and  formidable  oi^eration  comparatively  easy  and  safe. 

Case  YI. — Mr.  Joseph  T..  wholesale  liquor-dealer,  aged  sixty,  a  smoker,  had  been 
suffering  for  twelve  years  from  opaline  patches  of  the  tongue,  two  of  which,  situated 
on  the  left  side  of  the  organ,  developed,  toward  the  end  of  1886,  into  epitheliomata. 
The  otherwise  well-nourished  patient  suffered  also  from  chronic  interstitial  nephritis, 
as  evidenced  by  the  presence  of  albumen  and  hyaline  and  fine  granular  casts  in  the 
urine.  Fei.  10,  1887. — The  left  lingual  artery  was  deligated  under  chloroform  anaes- 
thesia. The  tongue  was  secured  by  a  strong  fillet  of  silk,  and  was  withdrawn  from  the 
mouth.  A  straight  Peaslee's  needle  was  then  carried  into  the  bottom  of  the  deligation 
wound,  and  was  thrust  through  the  middle  of  the  base  of  the  tongue  just  in  front  of 
the  epiglottis  into  the  oral  cavity.  One  end  of  a  platinum  wire  was  passed  through  the 
eye  of  the  needle,  withdrawn  through  the  wound  and  disengaged.  The  same  needle 
was  reintroduced  by  the  wound  into  the  oral  cavity,  emerging  this  time  just  alongside 
of  the  left  anterior  pillar  of  the  fauces.  The  other  end  of  the  wire  was  brought  out 
by  the  needle  through  the  external  wound.  Thus,  one  half  of  the  base  of  the  tongue 
was  included  in  a  loop,  and,  the  wire  being  connected  with  a  galvanic  battery,  was 
singed  through  without  loss  of  blood.  After  this  the  tongue  was  divided  longitudi- 
nally by  the  thermo-cautery  in  two  unequal  halves,  and  finally  was  severed  from  its 
connections  with  the  tloor  of  the  mouth  by  the  same  instrument.  A  few  spurting 
arteries  had  to  be  tied  off  during  this  last  step  of  the  operation,  which  was  completed 
within  the  time  of  forty  minutes.  The  haemorrhage  was  really  insignificant,  to  which 
circumstance  is  to  be  mainly  attributed  the  rapid  recovery  of  the  patient.  The  oral 
wound  was  packed  with  iodoformized  gauze,  and  the  external  incision  was  dressed  in 
the  normal  manner.  Tlie  temperature  remained  normal  throughout,  and  feeding  by 
tube  was  discontinued  on  the  third  day.  The  mouth  was  irrigated  every  hour  with  a 
1 : 1,000  permanganate  of  potash  solution,  until  February  18th,  when  the  packing  came 
away.  The  wound  appeared  clean,  and  rapid  contraction  was  manifest.  Feb.  25th. — 
The  external  wound  was  firmly  healed.     March  8th. — The  oral  wound  was  closed. 

XoTE. — In  preparing  iodoformized  gauze  for  use  in  wounds  of  the  oral  cavity  of  elderly 
subjects,  care  must  be  taken  not  to  sprinkle  too  much  of  the  chemical  upon  the  gauze.  The 
surplus  of  iodoform  should  be  rinsed  out  of  the  meshes  of  the  fabric,  which  should  be  tinged  just 
a  very  faint  yellow  color. 

Vni.     LARYNGEAL    OPERATIONS. 

1.  Tracheotomy. — The  belief  that  tracheotomy  is  an  easy  operation  is  by 
no  means  justitied  by  the  author's  experience.  Occasionally,  on  a  slender 
neck,  and  when  there  is  competent  assistance  to  be  had,  it  is  a  simple 
enough  procedure.  But  in  most  cases,  especially  on  children,  it  calls  for 
the  best  qualities  of  an  experienced  and  cool  surgeon. 

The  necessity  of  tracheotomy  having  become  manifest,  three  require- 
ments are  to  be  fulfilled.     First,  infection  of  the  wound  has  to  be  avoided  ; 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD. 


101 


secondly,  unnecessary  liseniorrhage  has  to  be  guarded  against ;  and,  thirdly, 
the  trachea  has  to  be  properly  incised,  and  the  cannula  properly  introduced 
and  secured. 

The  risks  of  the  operation  are  not  inconsiderable,  hence  intubation  of 
the  larynx,  a  much  simpler,  easier,  and  more  physiological  procedure,  must 

be  declared  to  be  far  preferable  to  tracheotomy 
where  its  application  is  proper,  as  in  croupous 
laryngitis. 

For  the  removal  of  foreign  bodies  and  in  cases 
of  tumor  of  the  larynx,  tracheotomy  will  remain 
the  proper  measure. 

Avoidance  of  infection  of 
the  wound  from  within  or 
without  is  an  ever  important 
matter  in  all  laryngeal  op- 
erations. But  it  is  especial- 
ly important,  and  also  more 
difficult,  in  cases  where  the 
operation  is  done  in  the  pres- 
ence of  an  infectious  process, 
as,  for  instance,  diphtheritic 
croup,  where  the  extension 
of  the  septic  condition  to 
the  external  wound  signal- 
izes a  very  grave  complication  of  the  otherwise  precarious  state  of  the 
patient. 

The  aseptic  rules  laid  down  in  preceding  parts  of  this  work  obtain  to 
their  full  extent  in  laryngeal  operations.  Infection  from  within  must  be 
guarded  against  by  careful  cleansing  of  the  external  wound  and  rubbing 
iodoform  powder  into  all  its  recesses  before  incising  the  trachea.  As  soon 
as  the  cannula  is  inserted,  the  external  wound  must  be  well  mopped  out  with 
a  sponge  soaked  in  corrosive-sublimate  lotion.  Then  it  is  dusted  with  iodo- 
form, and  lightly  packed  with  iodoformized  gauze.  In  all  cases  of  croup 
the  external  wound  should  not 
be  sutured,  as  sutures  favor  re- 
tention. A  small  slit  compress 
of  iodoformized  gauze  is  slipped 
in  under  the  flange  of  the  can- 
nula before  its  fastening  by  the 
two  lateral  pieces  of  tape.  By 
slipping  in  over  the  gauze  com- 
press a  slit  piece  of  rubber  tis- 
sue or  oiled  silk,  the  dressings  and  the  patient's  shirt  will  be  protected  from 
soiling  by  the  sputa.  A  narrow  roller  bandage  passed  several  times  over  and 
under  the  outer  opening  of  the  cannula  will  give  additional  security  against 
accidents. 


Fig.  95. — Arrangement  of  the  patient  for  tracheotomy. 


Fig.  96.— a,  Slit  compress,     b,  Same  in  situ. 


102  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

Note. — Unruly  diildren  will  sometimes  attempt  the  forcible  removal  of  the  cannula.  In 
1880  the  author  performed  tracheotomy  on  a  boy  twelve  year.s  old,  who,  on  regaining  conscious- 
ness, at  once  tore  out  the  cannula  from  the  wound,  breaking  its  fastenings  to  the  flange,  which 
remained  attached  to  his  neck.  The  family  attendant,  an  elderly  gentleman,  attempted  the 
re-introduction  of  the  instrument,  finally,  during  the  violent  struggles  of  the  patient  the 
cannula  slipped  into  place,  whereupon  respiration,  which  had  been  labored  before,  suddenly 
ceased  altogether.  The  author  reached  the  bedside  by  this  time,  and  at  once  removed  the 
cannula  from  the  asphyxiated  child's  neck,  restoring  respiration.  It  was  found  that  the  cannula 
had  been  introduced  upward  into  the  oral  cavity,  instead  of  downward  into  the  trachea.  Another 
tracheal  tube  was  properly  introduced,  and  peace  was  once  more  restored,  but  the  boy  died  sub- 
sequently of  septicaemia,  due  to  the  wide  extent  of  the  diphtheritic  affection  of  the  pharynx. 

Hmmorrhage,  always  characteristic  of  au  overhasty  and  bungling  opera- 
tion, can  be  guarded  against  by  observing  the  rules  laid  down  in  the  chaiiter 
on  the  technique  of  surgical  dissection.  Nothing  will  retard  the  perform- 
ance of  tracheotomy  as  effectively  as  the  disregard  for  haemorrhage.  And 
every  drop  of  blood  spilt  unnecessarily  will  proportionately  diminish  the 
cliances  of  recovery,  not  to  mention  the  danger  of  suffocation  from  the 
entrance  of  blood  into  the  lungs. 

XoTE. — The  author  once  assisted  a  colleague  who  in  his  anxiety  to  open  the  trachea  cut 
the  isthmus  of  the  thyroid  gland.  The  formidable  haemorrhage  following  this  step  only  increased 
the  doctor's  haste.  He  plunged  the  knife  into  the  pool  of  blood  and  fortunately  opened  the 
trachea.  The  patient  aspirated  a  large  quantity  of  blood,  and  would  have  surely  been  suffocated 
but  by  the  timely  turning  of  his  body  face  downward.    The  patient,  a  boy  of  seven  years,  recovered. 

As  soon  as  the  skin,  platysma,  and  superficial  fascia  have  been  amply 
divided,  the  two  groups  of  longitudinal  muscles  situated  in  front  of  the 
larynx  are  exposed.  Sharp  retractors  are  inserted  and  the  bleeding  vessels 
are  attended  to.  A  faint  white  mark  indicating  the  median  line  where 
the  muscles  meet,  is  incised,  and  the  muscles  are  taken  uj)  and  raised  by  the 
retractors  as  the  wound  deepens. 

Thus  far  everything  is  easy.  The  most  difficult  part  of  the  operation 
consists  in  the  proper  treatment  of  the  isthmus  of  the  thyroid  gland. 

Tlie  surgeon  must  decide  whether  to  approach  the  trachea  from  above  or 
below  the  isthmus,  and  this  decision  depends  upon  the  length  of  the  neck 
and  the  size  of  the  isthmus.  In  long,  slender  necks,  the  trachea  is  easily 
exposed  below  the  isthmus  ;  in  short,  fat  necks,  with  a  massive  isthmus,  the 
upper  operation  is  more  appropriate. 

a.  SuPEKiOR  Teacheotomy. — Having  chosen  the  upper  operation,  the 
surgeon  must  find  his  way  to  the  upper  part  of  the  trachea,  situated  just 
behind  the  isthmus,  without  injuring  the  thyroid  capsule  and  its  compli- 
cated plexus  of  large  and  turgid  veins.  To  accomplish  this,  Bose's  method 
affords  an  easy  way. 

The  deep  cervical  fascia  divides  into  two  layers  just  above  the  superior  margin  of 
the  thyroid  gland,  these  two  layers  forming  the  main  body  of  the  thyroid  capsule. 
The  point  of  division  corresponds  exactly  with  the  upper  margin  of  the  cricoid  carti- 
lage, which  can  be  easily  identified  by  touch.  The  nail  of  the  left  index  finger  is 
placed  against  the  margin  of  the  cricoid,  the  pulp  of  the  finger  looking  downward, 
whereby  the  thyroid  gland  is  protected,  and  the  fascia  is  opened  by  a  short  transverse 


SPECIAL  APPLICATION   OF   THE   ASEPTIC    ^lETHOD. 


103 


Fig.  97. — Diagram  showing  relations 
of  deep  cervical  fascia,  a.  Thy- 
roid body.  Just  above  it,  corre- 
sponding to  cricoid  cartilage,  bi- 
furcation of  deep  cervical  fascia. 


incision  directed  against  the  upper  edge  of  the  cartilage.  As  soon  as  this  is  done,  a 
blunt  hook  can  be  introduced  through  the  transverse  slit  behind  the  thyroid  gland, 
which  then  can  be  drawn  down  with  some  force,  exposing  the  two  or  three  upper  rings 

of  the  trachea.  The  author  never  saw  this  method 
fail,  and,  in  employing  it,  never  was  compelled  to 
cut  the  cricoid  cartilage  for  want  of  space  to  limit 
the  incision  to  the  trachea.     (See  Fig.  9T.j 

I.  IxFEKiOR  Teacheotomt. — When  the 
lower  operation  is  decided  on,  the  two  layers 
of  the  deep  cervical  fascia  are  successively 
incised  letween  two  forceps,  and  thus  the 
trachea  will  be  readily  ex^Dosed. 

Incision  of  the  tracliea  should  be  done 
by  the  scalpel  used  for  the  first  part  of  the 
operation,  and  rather  by  cutting  than  by 
puncture,  as  the  latter  may  injure  the  poste- 
rior wall  of  the  cylinder.  Before  cutting  it, 
the  trachea  should  be  allowed  first  to  adjust 
itself  in  its  normal  position,  so  that  the  in- 
cision should  be  placed  exactly  in  the  me- 
dian line. 

Gras]3ing  of  the  trachea  while  the  incision  is  being  made,  but  especially 
haste  in  opening  the  organ,  may  lead  to  very  serious  mistakes.  It  may 
happen  that  the  trachea  is  not  incised  at  all,  or,  what  is  still  worse,  the 
incision  is  placed  laterally  or  even  posteriorly  on  the  tilted  wind-pipe. 

Case  I. — Mary  E.,  aged  five.  May  4,  1882. — Tracheotomy  performed  by  a  col- 
league for  laryngeal  croup.  The  cannula  could  not  be  kept  back  in  the  wound,  and  the 
patient  was  found  by  the  author  suffocating,  the  instrument  ]ying  on  the  outside  of  the 
neck.  Examination  showed  that  the  tracheal  incision  was  placed  to  the  left  side  and 
posteriorly,  the  trachea  being  twisted  and  bent  while  the  cannula  was  in  situ.  An 
anterior  tracheal  incision  was  made,  and  in  this  the  tube  was  retained  withoat  trouble. 
The  child  died  of  pneumonia. 

Case  II. — Hermann  Alollenhauer,  aged  two  and  a  half.  Croupous  laryngitis. 
March  27,  1881. — With  the  assistance  of  the  family  attendant,  Dr.  Hase,  superior 
tracheotomy,  on  account  of  imminent  suffocation.  The  trachea  was  exposed  without 
trouble,  but  in  catting  it  open  too  hastily  it  tilted  around  its  axis,  and  the  point  of  the 
knife  shaved  off  a  segment  of  the  first  tracheal  ring.  The  tilting  of  the  trachea  was 
not  noticed  at  first  on  account  of  the  necessary  haste ;  but,  as  soon  as  it  was  discovered, 
the  trachea  was  properly  incised,  and  the  child  ultimately  recovered. 

As  soon  as  the-  proper  number  of  rings  are  divided,  the  lips  of  the  in- 
cision should  be  taken  up  by  two  small,  sharp  retractors.  (See  Fig.  18, 
page  40.)  Hasty  crowding  in  of  the  cannula  is  reprehensible,  and  may 
€ause  serious  or  fatal  mischief  by  detaching  and  jDushing  membrane  down 
into  the  deeper  parts  of  the  tracheal  tube.  DraAving  asunder  the  tracheal 
wound  will  afford  ample  opportunity  for  free  breathing,  for  ejection  of  blood 
and  membrane  or  mucus,  and  will  give  the  surgeon  a  welcome  chance  to 
inspect  the  trachea  and  to  extract  semi-detached  membrane  or  a  foreign 


104  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

body.  It  will  also  solve  the  question  whether  tracheotomy  has  accomplished 
its  end  or  not  by  the  relief  from  dyspnoea. 

The  apncea,  or  seeming  cessation  of  breathing,  often  observed  imme- 
diately after  the  incision  of  the  trachea,  is  apt  to  alarm  beginners.  It  is 
due  to  the  habituation  of  the  patient  to  exist  on  a  very  small  allowance  of 
oxygen.  The  tirst  deep  and  free  breath  taken  through  a  newly-made 
tracheal  incision  gives  the  patient  more  oxygen  than  ten  or  fifteen  labored 
inspirations  could  give  before  the  operation. 

As  soon  as  the  cannula  and  dressings  are  in  place,  the  patient  is  brought 
to  bed,  and  a  sponge,  hollowed  out  in  cup  shape  by  the  curved  scissors,  is 
attached  with  a  safet^'-piu  or  two  to  a  suitable  piece  of  bandage,  is  wrung 
out  of  hot  carbolic  lotion  (one  per  cent),  and  is  tied  down  loosely  just  over 
the  orifice  of  the  cannula.  It  should  be  cleansed  at  frequent  intervals 
in  the  same  lotion.  Close  attention  to  the  cleanliness  of  the  interior  of 
the  cannula  is  a  constant  duty  devolving  upon  the  nurse.  It  should  be 
done  by  chicken  or  pigeon  wing-feathers  dipped  in  carbolic  lotion.  The 
little  patients  should  be  encouraged  to  drink  as  much  as  possible,  prefer- 
ably milk. 

The  first  dressings  can  remain  undisturbed  for  three  days  ;  on  the  fourth 
day  they  and  the  cannula  are  changed.  The  patient  is  laid  out  flat  on  a 
table  as  for  tracheotomy,  and  everything  possibly  needed  should  be  at  hand 
and  readily  arranged  in  a  pan.  Two  sharp  retractors,  thumb-forceps,  scis- 
sors, a  clean  cannula,  and  a  change  of  dressings  will  be  needed.  The  bandages 
are  cut,  and  they  and  the  cannula  are  simultaneously  removed  with  the  outer 
compress  of  gauze.  The  deeper  packing  should  remain  unchanged  till  it 
becomes  detached.  The  fresh  cannula  is  slipped  in  at  once,  and  usually  with- 
out much  difficulty  if  the  procedure  be  not  unduly  delayed. 

The  packing  of  iodoformed  gauze  will  become  loose  on  about  the  fourth 
day,  and  should  then  be  removed.  If  the  wound  is  found  clean  and  granu- 
lating, no  repacking  will  be  required. 

As  soon  as  the  patient  can  breathe  freely  through  the  fenestra  of  the 
outer  tube,  the  external  opening  of  the  cannula  being  occluded,  the  instru- 
ment should  be  removed,  as  it  is  apt  to  cause  pressure-sores  and  trouble- 
some granulations  within  the  trachea. 

The  author's  experience  embraces  forty-four  tracheotomies  performed 
for  various  reasons.  Twenty-two  were  done  for  croupous  laryngitis  on  chil- 
dren. Of  these,  five  recovered  ;  seventeen  died.  The  superior  operation 
was  employed  seventeen  times  ;  the  inferior,  five  times. 

One  of  the  children  died  of  suffocation  caused  by  the  ill-advised  action 
of  the  father,  who  inflated  the  patient's  bronchi  through  the  cannula  with 
a  large  quantity  of  burnt  alum.  The  others  died  of  extension  of  the  pro- 
cess to  the  lungs,  or  of  septicaemia. 

Of  the  remaining  twenty-two  tracheotomies  done  on  non-croupous  cases, 
three  concerned  children,  nineteen  referred  to  adults. 

The  following  table  will  elucidate  the  causes  for  which  the  operation 
was  performed  : 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.         105 

Eecovered.     Died. 

Asphyxia  from  entrance  of  blood  into  trachea i  i 

"  "     malignant  goitre 2 

"  "     foreign  body  in  right  bronchus 1 

"  "     arterial  hemorrhage  into  a  cervical  abscess 1 

"  "      chloroform 1 

Dyspnoea  from  cicatricial  stenosis  of  bronchus i 

"  "  "  "         "larynx ,  1 

"  "  "  "         "  pharynx 1 

"  "     lymphosarcomata  of  neck 1 

"  "     sarcoma  of  tonsil  and  neck l 

"  "     laryngeal  tumor 3  2 

"  "     foreign  body  in  trachea 1 

"  "  "         "       "  larynx 2 

Preliminary  tracheotomy 2 

Total 13  9 

Of  the  two  cases  operated  on  for  the  entrance  of  blood  into  the 
larynx,  one  recovered  (see  Case  IV  on  page  99)  ;  the  other,  where  haemor- 
rhage came  from  a  suicidal  gunshot  wound  of  the  base  of  the  skull,  died 
of  the  cerebral  injury. 

In  two  cases  the  operation  was  done  for  threatening  asphyxia  by  grow- 
ing malignant  goitre.  Both  died  :  one  from  collapse  ;  the  other  from 
coma,  produced  by  acute  alcoholism  or  traumatic  delirium  (see  Cases  I 
and  II  on  page  113). 

In  one  case  asphyxia,  caused  by  hgemorrhage  into  a  cervical  abscess, 
necessitated  the  operation.  The  patient  recovered  (see  Case  III  on 
page  231). 

In  two  cases  tracheotomy  was  done  without  success  for  deep-seated  ste- 
nosis of  the  air-ducts. 

One  concerned  a  man  of  forty,  in  whose  left  bronchus  post-mortem  examination 
revealed  a  syphilitic  cicatricial  stenosis.  The  other  bronchus  was  found  compressed 
by  acute  swelling  of  a  bronchial  lymphatic  gland. 

The  other  case  was  that  of  Fred.  Peckary,  aged  one,  who  exhibited  symptoms  of 
a  growing  tracheal  stenosis,  principally  obstructing  expiratiori.  The  case  came, 
March  6,  1886,  under  the  author's  care  by  the  kindness  of  Dr.  Boldt.  Tracheotomy 
was  done  at  the  German  Hospital  without  relief.  The  child  died  of  pneumonia  March 
10th.  On  autopsy  a  brass  trousers-button  was  found  imbedded  in  old  cicatricial 
tissue  between  trachea  and  oesophagus,  midway  between  the  cricoid  cartilage  and  the 
bifurcation.  An  open  communication  existed  between  the  two  tubes.  The  button  was 
held  in  place  by  a  rim  of  cicatricial  tissue  in  the  oesophagus,  and  projected  downward 
with  its  free  lower  margin  like  a  valve  into  the  lumen  of  the  trachea.  Thus  inspira- 
tion found  no  impediment,  but  on  expiration  the  valve  was  raised,  and  expiration- 
stenosis  was  the  result. 

In  one  case  syphilitic  stricture  of  the  fauces  indicated  the  ojoeration. 
Patient  survived. 

In  five  cases  the  trachea  was  opened  on  account  of  the  presence 
of   laryngeal    tumors.      Three  survived,   and  two  died  of  septic  pneumo- 


106  EULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

Ilia,  due  to  aspiration  of  the  intensely  fetid  secretion  of  the  ulcerated 
tumors. 

Preliminary  tracheotomy  was  done  twice  successfully  before  extirpation 
of  cancerous  tumors. 

In  one  case  the  trachea  was  opened  on  account  of  acute  asphyxia  occur- 
ring during  chloroform  anaesthesia. 

Case. — Undersized  boy,  aged  nineteen.  Xovemher  12,  1889. — At  Mount  Sinai  Hos- 
pital removal  of  an  enormous  congenital  teratoma  of  the  occipital  region  under  cbloro- 
form.  The  growth  had  become  sarcomatous,  and  extensive  involvement  of  the  cer- 
vical glands  of  both  sides  was  present.  The  patient  had  to  be  placed  in  the  prone 
position,  and  this  and  his  generally  weak  state,  together  with  the  encroachment  on 
the  trachea  by  the  glandular  swellings,  produced  asphyxia  toward  the  end  of  the  oper- 
ation. As  artificial  respiration  did  not  seem  to  produce  any  effect,  tracheotomy  was 
performed  at  once,  and  respiration  was  restored.  While  the  pedicle  of  the  tumor  was 
being  detached,  it  was  noted  that  respiration  had  again  ceased.  The  cannula  was 
found  outside  of  the  tracheal  wound,  from  which  it  was  allowed  to  slip  by  the 
assistant  intrusted  with  the  narcosis.  It  is  fair  to  state  that  death  was  very  likely 
due  to  exhaustion  or  collapse  induced  by  the  shock  of  the  formidable  operation  upon 
the  much  emaciated  patient.  He  was  a  lad  of  nineteen,  but  looked  like  a  very  sickly 
child  of  ten. 

In  one  case  increasing  stenosis,  caused  by  the  presence  of  a  dispropor- 
tionately small  tumor,  indicated  the  operation. 

Case. — Julius  Meyer,  peddler,  aged  thirty-nine.  Prt-vious  history  pointed  at  the 
lodgment  of  a  foreign  body  in  the  oesophagus  with  dyspliagia,  which  spontaneously 
disappeared.  Gradually,  however,  increasing  dyspnoea  supervened.  The  laryngo- 
scope demonstrated  the  presence  of  a  small  irregular  tumor  in  the  larynx,  the  size  of 
which  did  not  seem  to  explain  the  intense  dyspnoea.  Tracheotomy  was  done  Decem- 
ber 18,  1886,  at  Mount  Sinai  Hospital.  On  incising  the  trachea  above  the  thyroid 
body,  a  granuloma  occupying  the  posterior  and  lateral  aspect  of  the  larynx  just  below 
the  vocal  chords  was  exposed.  Surrounded  by  this  mass  was  found  the  point  of  a 
icooden  sl'eicer,  one  inch  in  length,  its  ends  being  imbedded  in  the  mucous  mem- 
brane. The  cricoid  cartilage  was  divided,  the  body  was  extracted,  and  the  granu- 
loma was  excised.  Dec.  27th. — Tracheal  tube  was  removal.  (F(jr  continuation,  see 
Case  III  on  page  108). 

The  following  histories  of  the  removal  of  foreign  bodies  from  the  air- 
passages  conclude  the  series  of  the  author's  non-croupous  cases  of  tra- 
cheotomy : 

Case  I. — Clara  V.,  aged  five  and  a  half.  May  22,  1887. — A  foreign  body  entered 
the  larynx  of  the  patient,  causing  intense  fits  of  coughing  and  transient  attacks  of 
choking.  A  number  of  unsuccessful  attempts  at  endolaryngeal  removal  of  the  body 
were  made  the  same  day.  Finally,  the  body  became  lodged  in  the  right  bronchus, 
where  its  presence  was  made  out  by  the  sibilant  noise  heard  near  the  bifurcation 
and  the  absence  of  normal  respiration  sounds  over  the  entire  right  lung.  A  short, 
hacking  cough,  moderate  dyspnoea,  and  noisy  respiration  served  as  constant  remind- 
ers of  the  impending  danger.  June  IJfth. — During  a  coughing  spell,  suddenly  an 
alarming  asphyctic  attack  set  in,  followed  by  dysphagia,  aphony,  hoarse,  croupy 
cough,  and  distressing  dyspnoea.      Marked  laryngeal  stridor  and  diminished  respira- 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.        IQT 

tion  sounds  over  both   lungs  pointed  to  the  lodgment  of  the  foreign  body  in  the 
glottis.     Inferior  tracheotomy  being  performed,   the  dyspnoea  at  once  disappeared. 
The  foreign  body,  a  headless  and  armless  miniature  doll  of  porcelain,  five  eighths  of 
an  inch  long  and  three  eighths  of  an  inch  wide,  was  found  firmly 
wedged  in  the  glottis,  whence  it  was  extracted  through  the  wound 
without  difficulty.     The  wound  was  treated  openly,  and  the  child 
recovered.     (See  Fig.  98.) 

Case  II. — Josephine  0.,  aged  seven.  July  7,  1889. — A  large  white 
bean  was  aspirated  and  lodged  in  the  left  bronchus,  where  its  pres- 
ence was  diagnosticated  by  the  entire  absence  of  respiration  sounds  Ftg.  98. — Min- 
ever the  left  lung.  July  lOth  fever  set  in.  Author  saw  the  patient  mOTe/°from 
July  12th  at  Clayton,  N.  Y.,  witb  well-developed  pneumonia  of  the  larynx  by  tra- 

left  lung.     Eenioval  to  New  York  was  advised,  and  was  fortunately  Exact*^size 

accomplished  without  the  necessity  of  operating  in  the  railroad  car.  (Clara  V.) 

On  July  14th,  without  previous  warning,  the  bean  was  dislodged  by 
an  access  of  cough,  and  the  child  was  immediately  asphyxiated.  Dr.  E.  D.  Walker, 
being  in  constant  charge  of  the  patient,  at  once  incised  the  trachea,  and  thus  the 
immediate  danger  was  averted.  In  the  mean  time,  the  size  of  the  bean  being  steadily 
increased  by  the  accumulation  of  blood-clot  around  it,  asphyxia  became  very  pro- 
found, respirations  had  ceased,  radial  pulse  could  hardly  be  felt,  and  death  v?as 
imminent.  The  author  arriving,  the  child  was  put  on  the  table,  the  wound  was 
enlarged,  and  it  was  found  that  the  bean  was  resting  on  the  spur  of  the  bifurca- 
tion. A  soft  rubber  drainage-tube,  a  little  smaller  in  diameter  than  the  trachea, 
was  passed  down  to  the  foreign  body,  was  firmly  pressed  down  upon  it,  and  aspi- 
ration by  mouth  being  practiced,  was  sucked  up  to  the  external  wound.  There  it 
became  detached  and  fell  back  into  the  windpipe,  to  be  brought  in  sight  again  by  the 
next  movement  at  expiration,  when  it  was  luckily  seized  with  a  forceps  and  brought 
out  whole.  The  deep  collapse  was  overcome  by  artificial  respiration  and  general 
stimulation,  and  the  child  recovered  in  spite  of  the  pneumonia. 

2.  Laryngoflssure. — Fission  of  the  larynx  for  the  removal  of  tnmors 
or  a  foreign  body  was  performed  five  times  by  the  author.  In  one  case 
of  recurrent  diffuse  papilloma  a  very  good  final  result  Avas  secured.  In 
another  one,  done  for  epithelioma,  speedy  relapse  followed.  In  the  third 
case  the  presence  of  a  foreign  body  and  inflammatory  granuloma  required 
the  step.  The  body  and  new-growth  were  removed,  but  the  perichondritic 
inflammation  maintained  for  a  very  long  time  such  an  intense  swelling  of 
the  laryngeal  mucous  membrane  that  the  tracheal  cannula  had  to  be  worn 
until  June,  1887. 

Case  I. — Mrs.  C.  Lehmann,  twenty-four,  epithelioma  of  both  vocal  cords.  April 
11^  188Ji.—hX  the  German  Hospital,  larnygofissure  and  extirpation  of  both  vocal  cords 
and  the  adjacent  mucous  membrane  were  done.  April  15th. — Cannula  removed. 
April  30th  — Wound  healed.  Eelapse  manifesting  itself  soon  afterward,  excision 
of  the  larynx  was  done  in  the  summer  of  the  same  year  by  Dr.  F.  Lange,  who 
took  charge  of  the  service  at  the  General  Hospital  after  the  expiration  of  the  author's 
term. 

Case  II. — David  Popple  well,  machinist,  aged  forty-two;  recurrent  papilloma  of 
the  larynx,  that  had  been  treated  endolaryngeally  by  Dr.  Gleitsmann,  who  kindly  di- 
rected the  patient  to  the  author,  July  9,  1885. — Laryngofission  at  the  German  Hos- 
pital. Removal  of  the  posterior  half  of  right  vocal  cord ;  excision  of  several  dissemi- 
16 


108  EULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

nated  papiiloniata  and  searing  of  their  l)ase  by  the  thernio-cautery.  August  5th. — 
External  wound  healed ;  voice  much  improved. 

Case  III.— Julius  Meyer,  peddler,  aged  thirty-nine.  Recurrent  stenosis  after  trache- 
otomy (see  case  on  page  106)  done,  December  18,  1886,  for  the  removal  of  a  foreign  body 
and  granuloma  from  the  larynx.  Jamiary  ^7,  1887. — Laryngofissure.  Moderate  return 
of  the  new-growth  about  the  defect  of  the  mucous  membrane  in  which  the  end  of  the 
•wooden  splinter  had  been  found  imbedded.  The  probe  was  introduced  into  this  aper- 
ture, and  penetrated  downward  and  backward  to  a  distance  of  three  fourths  of  an  inch, 
thin  pus  exuding  from  the  sinus.  Intense  swelling  and  hypersemia  of  the  entire  mucous 
membrane  and  submucous  tissue  were  noted.  Perichondritis  was  diagnosticated,  and 
a  tracheal  tube  was  left  inserted  in  the  wound.  The  patient  readily  recovered  from 
the  operation,  but  subsequently  could  not  get  along  without  a  cannula  till  June,  1887. 

Case  IV. — P.  Lewin.  Laryngofissure  and  extirpation  of  tubercular  tumor  of  larynx. 
Subsequent  laryngoplasty.     See  "New  York  Medical  Record,"  April  6,  1889. 

Case  V. — Fanny  Kupfer,  aged  sixty.  Chronic  suppurative  perichondritis  with 
partial  necrosis  of  thyroid  cartilage.  Laryngofissure  October  25,  1889,  at  Mount  Sinai 
Hospital.  Laryngeal  fistula  closed  by  laryngoplasty  February  14,  1890.  Discharged 
cured,  March,  1890. 

3.  Extirpation  of  the  Larynx. — There  is  no  doubt  in  the  author's 
mind  that  partial  or  total  extirpation  of  the  larynx  for  malignant  new- 
growths,  if  done  early,  is  the  correct  treatment,  and  will  be  successful  in 
direct  proportion  to  the  readiness  and  thoroughness  with  which  it  is  done. 
This  view  is  in  full  accord  with  the  accepted  principles  of  the  treatment 
of  malignant  neoplasms  of  all  other  regions  of  the  body.  The  large  rate 
of  mortality  recorded  so  far  after  extirpation  of  this  organ  is  due  in  a 
great  measure  to  the  fact  that  tlie  steji  was  resorted  to  mostly  in  hopeless 
and  desperate  cases,  in  wliich  endolaryngeal  therapy  had  utterly  failed  to 
give  relief.  How  the  precious  opportunity  is  lost  of  rendering  substantial 
aid,  or  even  securing  durable  relief,  was  illustrated  by  a  famous  case  which 
not  long  ago  engaged  the  interest  of  the  whole  civilized  world.  Generally 
the  course  of  events  is  as  follows  :  A  laryngeal  tumor  of  doubtful  character 
being  noticed,  its  cure  is  attempted  by  necessarily  imperfect  and  superficial 
endolaryngeal  methods  at  removal,  which,  however  adequate  for  the  treat- 
ment of  benign  new-growths,  are  unquestionably  unreliable  so  far  as  the 
eradication  of  a  malignant  neoplasm  is  concerned.  The  repeated  employ- 
ment of  caustics  or  the  application  of  forceps  will  not  only  fail  to  eradicate 
all  the  elements  of  evil,  but,  on  the  contrary,  will  serve  as  a  stimulus  to  the 
rapid  extension  of  the  malady  to  the  unaffected  parts  of  the  organ.  False 
hopes  thus  raised  by  professional  ignorance  or  cui^idity  are  not  only  doomed 
to  disappointment  by  unmistakable  recurrence,  but  the  chances  of  relief  are 
marred  by  the  further  dissemination  of  the  infectious  elements  in  tlie  dis- 
eased organ  itself  and  to  the  pertinent  lymphatic  glands. 

The  earlier  the  ojjeration  is  done  after  due  establishment  of  the  diag- 
nosis, the  less  mutilating  it  need  be.  Unilateral  extirpation  of  the  larynx 
is  far  less  dangerous  than  the  total  removal  of  that  organ,  and,  as  a  num- 
ber of  successful  cases  testify,  even  a  fair  degree  of  phonation,  together 
with  unimpaired  deglutition,  may  be  preserved  by  it. 


SPECIAL  APPLICATION  OF  THE   ASEPTIC  METHOD.         109 

Case  I.* — Paul  Hahn,  barber,  aged  fifty.  November^  1879. — Increasing  dysphagia. 
Dr.  E.  Gruening  diagnosticated  an  elevated  ulcer  of  the  size  of  a  half-dollar  coin,  occupy- 
ing the  depression  bounded  by  the  right  side  of  the  base  of  the  epiglottis,  the  right  side 
of  the  base  of  the  tongue,  and  the  right  wall  of  the  pharynx,  a  site  corresponding  to 
that  of  the  glosso-epiglottic  and  aryteno-epiglottic  folds,  and  more  particularly  to  that  of 
the  sinus  pyriformis.  The  mucous  coveinng  of  the  epiglottis  was  seen  to  be  thickened 
and  congested.  The  cervical  glands  did  not  appear  to  be  affected.  No  evidence  of 
syphihs  could  be  elicited,  either  from  the  history  or  from  the  physical  examination  of  the 
patient,  excepting  a  moderate  degree  of  onychia,  characterized  by  roughening  of  the 
finger-nails.  In  the  course  of  the  treatment  it  became  evident,  however,  that  this  latter 
trouble  was  due  only  to  the  fact  that,  in  pursuing  his  trade,  his  fingers  were  much  ex- 
posed to  the  action  of  soap-lather. 

Anti-syphilitic  treatment  was  instituted  and  continued  for  some  time  with  apparent 
benefit,  the  patient  regaining  to  a  certain  extent  the  ability  to  swaUow.  The  improve- 
ment was,  however,  merely  temporary ;  the  dysphagia  returned,  and  the  patient  soon 
began  to  suffer  from  the  inanition  thus  engendered. 

Preliminary  tracheotomy  was  performed  January  18,  1880,  at  the  German  Hospital. 
March  5,  1880. — Unilateral  exsection  of  the  larynx  was  done  with  the  able  assistance  of 
Drs.  Gruening,  Bopp,  Lefferts,  and  Dr.  Degner,  the  house-surgeon,  to  whom  great 
credit  is  due  for  the  skill  and  patience  exhibited  in  the  difiicult  and  tedious  after-man- 
agement of  the  case. 

An  incision  was  carried  from  the  median  line  of  the  hyoid  bone  along  its  upper 
margin  outward  to  the  extent  of  thi-ee  inches,  exposing  the  right  lingual  artery,  which 
was  ligated.  A  second  incision  was  carried  downward  from  the  starting-point  of  the 
first,  in  the  median  line,  to  the  opening  for  the  cannula,  exposing  the  anterior  surface  of 
the  hyoid  bone  and  larynx,  and  the  flap  thus  formed  was  dissected  np  with  all  the 
underlying  soft  parts  and  turned  outward.  Trendelenburg's  tampon-cannula  had  been 
fitted  into  the  trachea.  The  right  half  of  the  hyoid  bone  was  then  exsected,  a  double 
ligature  placed  around  the  superior  lai*yngeal  artery,  and  the  same  divided.  The  crico- 
thyroid ligament  was  cut  across,  a  pair  of  bone  scissors  inserted  into  the  larynx,  and 
the  thyroid  cartilage  divided  in  the  median  line.  Trendelenburg's  tampon  cannula  did 
not  fulfill  the  requirements  owing  to  a  leak  in  the  inflated  bladder,  so  that  blood  man- 
aged to  find  its  way  into  the  trachea.  An  attempt  to  make  it  serviceable  by  winding 
layers  of  moistened  gauze  around  the  cannula  was  unsuccessful,  and  during  the  rest  of 
the  operation  it  became  necessary  to  fill  out  the  lower  part  of  the  larynx  with  small 
sponges.  The  interior  of  the  larynx  was  now  exposed  and  showed  an  oval  tumor,  of 
about  the  size  of  a  pigeon's  egg,  situated  in  the  substance  of  the  right  false  vocal  cord, 
involving  the  posterior  half  of  the  true  vocal  cord  and  the  small  cartilages  belonging 
to  it.  The  right  half  of  the  thyroid  and  the  whole  of  the  arytenoid  cartilage  were 
now  dissected  up  and  removed,  together  with  the  whole  epiglottis.  The  pharynx  being 
thus  exposed  to  view,  its  entire  right  side  was  seen  to  be  diseased,  and  was  removed, 
together  with  the  right  tonsil  and  the  lower  half  of  the  right  pillars  of  the  palate.  The 
base  of  the  tongue,  likewise  involved,  was  dissected  up  on  the  right  side  with  the 
scalpel,  on  the  left  with  the  thermo-cautery.  The  hsemorrhage  was  insignificant,  and 
the  patient  rallied  promptly  after  the  operation. 

One  of  Tiemann's  excellent  soft-rubber  tubes  was  introduced  into  the  oesophagus, 
the  wound  thoroughly  cleansed  with  a  ten-per-cent  solution  of  zinc  chloride,  and  the 
whole  cavity  packed  with  moistened  balls  of  carbolized  cloth.  The  edges  of  the  hori- 
zontal incision  were  then  united  by  catgut  sutures. 

*"  Archives  of  Laryngology,"  vol.  i,  No.  2,  June,  1880. 


110  RULES  OF  ASEPTIC  AND   ANTISEPTIC  SURGERY. 

The  oesophageal  tube  was  remarkably  well  tolerated,  and  the  patient's  nourishment 
was  satisfactorily  effected  through  it  during  the  whole  course  of  the  treatment. 

The  dressing  was  clianged  once  every  twenty-four  hours. 

On  the  fifth  day  after  the  operation  the  patient  was  well  enough  to  sit  up  in  a 
chair  for  an  hour.  Three  days  later  he  could  ascend  a  flight  of  stairs  in  being  removed 
to  another  room,  and  a  week  later  he  spent  most  of  his  time  out  of  bed.  By  the  1st 
of  April,  twenty-six  days  after  the  operation,  he  took  a  walk  in  the  garden,  and  his 
weight  had  increased  by  6^  pounds. 

The  large  cavity  contracted  rapidly,  and  finally  became  a  canal,  bounded  on  one 
side  by  the  remaining  half  of  the  larynx,  on  the  other  by  a  smooth  cicatrix  uniting  the 
skin  with  the  raucous  membrane  of  the  posterior  wall  of  the  pharynx. 

On  the  29th  of  April  the  patient  made  a  first  attempt  to  speak.  When  the  tracheal 
tube  was  closed,  he  could  converse  with  a  hoarse,  dull  voice,  quite  audible,  and  easily 
understood  at  a  distance  of  from  two  to  three  yards.  His  ability  to  swallow  has  in  a 
measure  been  recovered,  but  he  preferred  to  use  the  oesophageal  tube,  to  which  he  had 
become  accustomed.     By  the  5th  of  May  he  had  gained  14^  pounds  in  weight. 

The  patient  continued  well  until  February,  1881,  when  he  contracted  an  acute 
pleurisy,  to  which  he  succumbed  rather  suddenly  on  account  of  fatty  heart.  The  speci- 
men of  the  larynx  gained  at  the  i)Ost-mortem  examination  showed  absence  of  any  sign 
of  a  relapse. 

The  tumor  was  found  to  be  an  adeno-sarcoraa. 

Case  II.* — Henry  O.,  porter,  aged  fifty-seven.  Rebellious  hoarseness  of  five 
months'  standing,  with  increasing  difficulty  of  deglutition.  Marked  loss  of  flesh  and 
power.  March  16,  1885. — When  the  patient  was  directed  to  the  author  by  Dr.  S.  W. 
Gleitsmann,  a  deep-seated,  nearly  immovable,  hard,  glandular  swelling  of  the  size  of  a 
hen's  egg  was  noted  in  the  left  submaxillary  triangle.  Endolaryngeal  inspection 
revealed  the  presence  of  a  smooth,  pale  tumor,  the  size  of  an  almond,  commencing  in  the 
left  glosso-epiglottidian  fold  and  extending  through  the  substance  of  the  left  vocal 
cord  into  the  ary-epiglottidian  fold,  to  terminate  in  the  arytenoid  cartilage  with  a  knob- 
like protuberance.  March  18th. — Chloroform  being  administered,  the  diseased  glands 
were  removed.  The  sterno-mastoid  was  found  partly  involved,  and  this,  together 
with  a  piece  of  the  internal  jugular  vein  of  about  one  and  a  half  inch  in  length,  was 
removed  in  one  mass.  Then  inferior  tracheotomy  was  performed.  The  wound  healed 
kindly,  except  where  tlie  tracheal  tube  was  located,  and  April  27th.  under  chloroform, 
the  left  half  of  the  larynx  was  removed.  A  tampon  cannula,  made  by  George  Tiemann 
&  Co.  after  the  author's  directions,  was  inserted  and  suitably  distended  so  as  to  pre- 
vent the  entrance  of  blood  into  the  trachea.  After  this  an  incision,  commencing  at 
the  upper  notch  of  the  thyroid  cartilage  and  extending  to  the  lower  margin  of  the 
cricoid  cartilage,  laid  bare  the  larynx  in  the  median  line.  To  this  was  added  another 
incision,  commencing  in  the  upper  angle  of  the  first  cut  and  extending  horizontally  to 
the  anterior  margin  of  the  left  sterno-mastoid  muscle.  The  crico  thyroid  ligament  was 
split  to  admit  a  strong  pair  of  bone-pliers  for  the  division  of  the  thyroid  cartilage  ;  but 
it  was  found  impossible  to  perform  this  act,  as  the  strongly  inclined  position  of  the 
cartilage  did  not  permit  an  effective  handling  of  the  instrument.  Therefore,  access 
was  gained  through  an  incision  in  the  thyro-hyoid  ligament  from  above,  and  in  this 
manner  an  exact  division  of  the  calcified  cartilage  was  successfully  effected.  After 
this  the  epiglottis  was  cut  through  lengthwise,  the  left  half  of  the  crico-thyroid  liga- 
ment was  divided,  and  tlie  superior  thyroid  artery  was  included  in  a  double  ligature 
and  cut  through.  The  most  diflicult  part  of  the  operation  consisted  of  the  dissection 
of  the  lateral  portions  of  the  larynx  and  pharynx,  closely  adherent  to  the  carotid  artery 

*  "  Annals  of  Surgery,"  January,  1 886,  p.  20. 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.        Ill 

l)y  cicatricial  tissue,  caused  by  the  extirpation  of  tiie  submaxillary  glands.  Shallow 
incisions,  running  parallel  with  the  course  of  the  carotid  artery,  were  cautiously  made 
•one  after  another,  and  the  difficult  task  seemed  almost  completed  when  suddenly  a 
powerful  jet  of  arterial  blood  welled  up  from  the  bottom  of  the  wound.  The  bleeding 
point  was  easily  secured  in  a  pair  of  artery  forceps,  and  then  it  was  ascertained  that 
the  trunk  of  the  superior  thyroid  artery  (doubly  ligated  further  below  prior  to  this) 
had  been  cut  away  on  a  level  with  its  inosculation  into  the  carotid.  A  catgut  liga- 
ture was  applied  around  the  main  trunk  above,  another  below  the  artery  forceps,  and 
when  the  instrument  was  removed  a  round  hole  in  the  side  of  the  carotid  became  visi- 
l)le.  The  remaining  adhesions,  corresponding  to  the  lateral  portion  of  the  pharynx  on 
the  left  side,  could  now  be  easily  dissected  out.  The  tampon  cannula  was  removed,  and 
it  was  found  that  no  blood  whatever  had  entered  the  trachea.  A  soft  tube  was  in- 
serted into  the  oesophagus,  the  wound  was  loosely  packed  with  iodoformed  gauze,  and 
an  ordinary  tracheal  cannula  was  left  in  the  lower  angle  of  the  tracheal  wound.  Finally, 
the  horizontal  incision  was  closed  by  a  number  of  catgut  sutures.  The  duration  of  the 
operation  was  one  hour  and  three  quarters^ — the  antesthesia  throughout  undisturbed. 

Microscopical  examination  of  the  new-growth  by  Dr.  L.  TValdstein  gave  the  diag- 
jaosis  of  alveolar  sarcoma. 

The  subsequent  course  of  the  wound  was  very  satisfactory  and  free  from  fever  or 
suppuration,  the  patient's  only  complaint  being  a  rather  profuse  secretion  of  saliva. 
Nutrition  was  carried  on  by  the  oesophageal  tube,  the  patient  consuming  considerable 
■quantities  of  milk,  eggs,  and  an  emulsion  composed  of  beef-tea  and  crushed  boiled  beef; 
"finally,  a  generous  supply  of  good  whisky. 

From  May  10th  on,  the  oesophageal  sound  was  introduced  twice  daily  for  purposes 
of  nutrition.  On  May  13th  the  tracheal  cannula  was  abandoned.  On  the  same  day 
the  innermost  layers  of  the  iodoformed  gauze  packing  became  detached,  and  were 
replaced.  The  entire  wound  was  found  to  be  in  a  vigorous  process  of  granulation,  and 
was  considerably  contracted. 

May  loth. — The  patient  swallowed  a  small  quantity  of  coifee. 

May  27th. — Sutures  were  removed ;  wound  firmly  united.  Increase  of  body  weight 
four  and  a  half  pounds.  May  31st. — Patient  was  discharged  cured  from  the  hospital, 
good  deglutition  being  noted.  June  12th. — Removal  of  a  small,  suspicious  gland  from 
the  left  supraclavicular  space.  March  13.,  1886. — Removal  of  an  enlarged  lymphatic 
gland  from  left  suprahyoid  region.  Since  then  the  patient  remained  well,  attending 
to  his  laborious  occupation.  He  could  speak  with  a  very  audible  hoarse  intonation. 
The  right  vocal  cord  performed  its  function  normally.  In  March,  1887,  relapse 
appeared  in  the  cicatrix  about  the  insertion  of  the  stump  of  the  epiglottis,  for  which 
subhyoid  pharjTigotomy  was  performed,  x\pril  22,  188T,  at  the  German  Hospital.  A 
portion  of  the  cicatrix,  together  with  a  section  of  the  base  of  the  tongue,  was  removed. 
The  external  wound  was  united  by  three  rows  of  superimposed  catgut  sutures.  Deg- 
lutition was  hardly  disturbed  by  the  operation;  the  external  wound  healed  by  adhe- 
sion, and.  May  8d,  patient  was  discharged  cured. 

In  both  of  the  preceding  cases  decided  alleviation  of  the  patients' 
■wretched  condition  and  an  undoubted  prolongation  of  life  were  achieved. 

IX.     GOITRE. 

The  aseptic  method  and  an  improved  technique  of  dissection  have 
materially  reduced  the  formidable  perils  of  the  surgical  treatment  of  goitre, 
justly  dreaded  by  old-time  practitioners. 


112  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

In  goitre  encroaching  upon  the  trachea,  the  question  must  be  first  de- 
cided whether  the  growth  is  cystic  or  parenchymatous.  If  cystic,  various 
forms  of  treatment  offer  a  fair  chance  of  cure.  The  cyst  can  be  tapped  and 
injected  with  tincture  of  iodine,  like  a  hydrocele  ;  or  it  can  be  exposed  by 
dissection,  incised,  and  its  walls  sutured  to  the  skin,  like  the  sac  in  hydro- 
cele operated  on  by  Volkmann's  method  (Schiuzinger). 

Case. — Lena  Kaiser,  aged  thirty-five.  Cystic  goitre  of  the  thyroid  body.  It  was 
as  large  as  a  child's  fist,  and  the  source  of  much  discomfort  to  the  patient  on  account 
of  the  severe  dyspnoea  it  produced,  yovernber  23,  1882. — At  the  German  Hospital, 
exposure  of  the  capsule  of  the  goitre.  A  plexus  of  much-distended  veins  was  included 
in  two  sets  of  double  mass  ligatures,  between  which  the  capsule  was  cut  into.  The 
parenchyma  of  the  gland  was  divided,  and  the  sac  of  the  cyst  being  exposed  was 
incised  and  attached  to  the  skin  by  two  continuous  sutures.  The  cavity  was  packed 
with  carbolized  gauze.     December  22d. — Patient  was  discharged  cured. 

Where  the  presence  of  a  number  of  contiguous  cysts  is  made  out,  their 
enucleation  will  be  appropriate.  The  procedure  is  not  difficult,  and  offers 
the  additional  advantage  of  the  possibility  of  primary  union  and  a  speedy 
cure. 

Case. — Hannah  S.,  servant,  aged  thirty-one.  January  16,  1886. — At  Mount  Sinai 
Hospital,  extirpation  of  four  contiguous  cysts  of  the  thyroid  body.  Flap  incision ;  the 
thyroid  capsule  was  cut  into  between  two  rows  of  mass  ligatures;  after  this  the  cysts 
were  shelled  out  without  dithculty.  The  wound  was  drained  and  sutured.  Primary 
union.     Patient  was  discharged  cured  February  21st. 

Parenchymatous  goitre  may  be  treated  with  some  hope  of  success  by  the 
methodical  injection  of  tincture  of  iodine  in  cases  in  which  the  tumor  is 
soft  and  vascular.  Should  this  plan  fail,  or  when  the  tumor  is  very  dense 
and  hard,  excision  must  be  performed. 

Total  removal  of  the  thyroid  gland  is  apt  to  produce  a  deep  alteration  of 
the  general  condition  denoted  '^ myxmdema"  or  ^'cachexia  strianipriva" 
(Kocher),  characterized  by  idiotism.  loss  of  sexual  powei*,  and  general  dense 
cedematous  infiltration  of  the  subcutaneous  connective  tissue  ending  in  death. 
Hence,  a  portion  of  the  glandular  tissue  ought  to  be  always  left  behind  to 
perform  its  function,  so  necessary  to  the  healthy  state  of  the  nervous  system. 

The  principles  laid  down  for  the  safe  removal  of  tumors  (page  52)  should 
guide  the  surgeon  in  exsecting  thyroid  swellings.  Haemorrhage  from  the 
large  veins  of  the  capsule  is  to  be  avoided  by  the  timely  use  of  Thiersch's 
spindles  and  of  double  ligatures.  Dissection  should  be  systematic  and  de- 
liberate, and  especial  care  should  be  devoted  to  the  preservation  of  the  re- 
current laryngeal  nerve,  which  will  be  found  behind  the  lateral  lobe  of  the 
thyroid  gland  in  the  groove  separating  the  trachea  from  the  oesophagus. 

Case. — Eosa  Rosenfeld,  cook,  aged  twenty-four.  Parenchymatous  hyperplastic 
goitre  of  the  body  and  right  thyroid  lobe,  causing  severe  dyspnoea.  October  9,  188^. — 
At  Mount  Sinai  Hospital,  extirpation  of  the  right  lobe  and  body  of  the  gland  from  a 
spacious  flap  incision.  A  pedicle  was  formed  toward  the  left  lobe,  and,  being  first  liga- 
tured, was  cut  off.  In  dissecting  up  the  right  lobe,  which  was  found  to  be  insinuated 
between  the  trachea  and  oesophagus,  the  recurrent  laryngeal  nerve  was  separated  and 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.        113 

drawn  aside.  Drainage,  suture,  and  aseptic  dressings.  The  wound  healed,  with  the 
exception  of  the  drainage-tracks  under  the  first  dressing,  which  was  changed  on  Octo- 
ber 19th.  Some  hoarseness  due  to  paresis  of  the  right  vocal  cord  persisted  for  five 
months,  but  ultimately  disappeared. 

Traclieotomy  for  goitre  is  one  of  the  most  formidable  tasks  the  surgeon 
may  be  called  upon  to  perform.  It  was  twice  the  author's  duty  to  under- 
take this  procedure  for  extreme  dyspnoea  caused  by  malignant  tumor  of  the 
thyroid  gland.  One  case  was  complicated  by  mitral  insufficiency  and  acute 
broncho-pneumonia,  and  ended  fatally.  In  the  other  one  the  supra-sternal 
portion  of  a  very  large  fibro-sarcoma  of  the  thyroid  gland  had  to  be  first 
extirpated  before  access  could  be  had  to  the  trachea.  This  case  also  ended 
lethally. 

Oa.se  I. — Rosa  Guttmann,  widow,  aged  thirty-six.  Large  and  growing  originally 
parenchymatous,  later  sarcomatous,  substernal  goitre  of  five  years'  standing.  Mitral  in- 
sufficiency and  severe  acute  broncho-pneumonia.  Dr.  S.  Kohn,  who  referred  the  patient 
to  the  author,  diagnosticated  paralysis  of  the  right  vocal  cord.  Noveinber  11^  1879. — 
Patient  was  admitted  to  German  Hospital  in  a  very  exhausted  condition.  After  copious 
stimulation  tracheotomy  was  performed.  Only  a  very  small  amount  of  ether  was  admin- 
istered for  the  cutaneous  incision.  Division  of  the  goitre  by  the  therm o-cautery  was 
tried,  but  had  to  be  given  up  on  account  of  the  slowness  of  the  process  and  the  great 
haemorrhage  from  the  enormously  distended  veins.  The  expedient  of  at  once  taking 
Tip  and  firmly  retracting  the  divided  tissues  by  large,  four-pronged,  sharp  hooks,  proved 
more  efficacious  in  checking  hsemorrhage.  With  a  few  rapid  strokes  the  trachea  was 
exposed  and  opened,  and,  a  large-sized  soft  catheter  being  introduced,  respiration  be- 
came well  established.     But  a  few  minutes  afterward  patient  expired. 

Case  II. — Elizabeth  K.,  aged  sixty-two.  A  very  fat  woman,  with  a  small  pulse, 
suffering  from  extreme  dyspnoea  due  to  the  presence  of  a  very  large  and  hard  supra- 
and  infra-sternal  fibro-sarcoinatous  goitre.  August  23,  1882. — Extirpation  of  the 
supra-sternal  part  of  the  swelling  with  subsequent  tracheotomy,  for  which  a  specially 
■constructed  cannula  with  a  long  tube  was  used.  Relief  of  dyspnoea.  Copious  stimula- 
tion was  employed  by  the  family  attendant  to  such  an  extent  that  in  the  night  of 
August  24th  the  patient  became  boisterously  drunk,  and  died  in  a  soporous  condition 
under  the  symptoms  of  acute  alcoholism. 

X.     AMPUTATION    OF    THE    BREAST. 

In  preantiseptic  practice  the  rate  of  mortality  observed  after  amputa- 
tion of  the  breast,  mainly  due  to  accidental  wound  comjjlications,  was  nearly 
as  high  as  that  of  major  amputation  of  the  limbs. 

The  notable  depression  of  the  death-rate  that  has  taken  place  since  is 
•directly  due  to  cleanlier  methods. 

The  absence  of  a  proportionate  decrease  of  the  death-rate,  caused  by  re- 
lapse of  the  malignant  growths  for  which  the  operation  is  performed,  is  to 
be  attributed  to  the  tardiness  of  the  general  practitioner  in  advising  and 
urging  early  removal,  and  the  unwillingness  of  the  patients  to  heed  timely 
advice. 

In  view  of  the  fact  that  over  ninety  per  cent  of  all  mammary  tumors 
are  carcinomatous,  the  benefit  of  the  doubt  belongs  to  the  view  which  urges 


lU 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


to  removal.  ^-1  probatory  incision  at  least  sliouhl  be  insisted  on  in  every 
case  of  solid  chronic  intumescence  of  the  breast  that  remains  iinitijiuenced 
by  proper  local  and  general  treatment  directed  against  syphilis  or  chronic 
infla mmatory  mastitis. 

Partial  operations  are  admissible  only  where  the  youth  of  the  patients, 
the  smoothness  and  mobility  and  slow  progress  of  the  tumor  justify  the 
assumption  of  a  benign  growth,  such  as  adenoma  or  adeno-fibroma,  or 
where  probatory  puncture  leaves  no  doubt  of  the  presence  of  a  simple  re- 
tention cyst. 

In  these  cases  the  operation  proposed  by  T.  G.  Thomas  is  very  appro- 
priate, and  gives  satisfactory  results  both  as  to  the  comjDleteness  of  the  re- 
moval and  the  cosmetic  effect.  The  incision  is  laid  in  the  pectoro-mammal 
fold,  and  the  breast-gland  is  raised  from  the  pectoral  fascia  sufficiently  to 
enable  the  surgeon  to  incise  it  on  its  posterior  aspect.  After  the  enucleation 
of  the  tumor  the  breast  is  replaced,  and,  the  wound  being  drained,  the 
skin  is  united  by  an  exact  suture.  The  cicatrix  remains  hidden  under 
the  overlapping  breast. 

Case  I. — Miss  C.  L.,  governess,  aged  twenty.  Adenoma  of  left  breast  of  tlie  size 
of  a  hen's  egg.     December  12^  I884. — At  Mount  Sinai  Hosi^ital,  Tliomas's  operation. 

Decemher  22d. — First 
change  of  dressings. 
Decemher  2Jfth. — Dis- 
charged cured.  De- 
cember 12,  1886.— liJo 
relapse ;  very  fine  lin- 
ear cicatrix. 

Case  II.  —  Miss 
Tillie  G.,  aged  six- 
teen. Adeno-fibroma 
of  left  breast  of  the 
size  of  a  small  apple. 


Fig.  'j'.'.— Tiji 


iiaiumary  trlaiul  beincr  detached  from  below,  the  surgeon  inserts  his  left  hand 
under  the  breast  to  complete  the  upper  section. 


SPECLA.L  APPLICATION  OF  THE  ASEPTIC  METHOD. 


115 


Deceriiber  20,  1886. — Thomas's  operation  at  Mount  Sinai  Hospital.     December  30th. — 
Dressings  changed.     January  4,  1881. — Wound  firmly  united. 

Whenever  amjratation  of  the  breast  is  performed  for  malignant  tumor, 
the  operation  must  he  radical,  or  at  least  as  radical  as  possible.  No  regard 
ivliatever  should  be  paid  to  cosmetic  considerations,  the  object  of  the  measure 
being  the  extirj^ation  of  a  deadly  disease,  which,  if  not  eliminated,  is  sure 
to  Mil.  A  wide  berth  should  be  given  to  the  visible  limits  of  the  disease, 
and  the  knife  should  take  away  at  least  an  inch  and  a  half  of  a^Dparently 
healthy  skin.  The  pectoral  fascia,  axillary  fat  and  glands  must  be  invari- 
ably removed  in  mass,  whether  intumescence  is  to  be  felt  or  not.  If  the 
axillary  vein  be  attached  to  degenerated  lymphatic  glands,  the  attached  seg- 
ment must  be  included  in  two  ligatures,  and  the  intervening  piece  cut  out 
together  with  the  adherent  mass.     (See  case  of  Betty  Lowy,  page  59.) 

The  technique  of  breast  amputation  is  simple.  After  marking  by  a 
shallow  cut  the  extent  of  the  two  semi-elliptic  incisions  that  should  include 

the  part  to  be  removed,  the  infe- 
rior margin  of  the  breast-gland  is 
exposed.  The  pectoral  fascia  be- 
ing incised,  the  mamma  is  gradu- 
ally dissected  up  from  the  thorax 
till  its  upper  limit  is  reached. 
The  surgeon's  hand  is  slipped  in 
under  the  breast,  and  the  upper 
incision  completes  its  detachment, 
except  where  the  lym- 
phatic vessels,  pass- 
ing along  the  pecto- 
ral fold  from  the 
breast  to  the  arm- 
pit, form  a  sort  of  a 
pedicle.  The  bleed- 
ing vessels  are  secured 
as  they  are  cut,  and 
the  pectoral  wound  is 
covered  with  a  towel 
wrung  out  of  corros- 
ive-sublimate lotion, 
to  remain  under  its  protection  during  the  removal  of  the  axillary  contents. 
The  incision  is  extended  well  up  the  arm  into  the  axilla,  and  the  skin  is  dis- 
sected up  for  about  an  inch  to  each  side  of  the  cut.  The  fascia  is  divided 
where  the  incision  can  be  made  boldly  upon  the  edge  of  the  pectoral  muscle 
anteriorly,  and  the  latissimus  dorsi  j)osteriorly.  Proceeding  from  this  latter 
incision,  the  loose  connective  tissue  is  divided  by  blunt  dissection  with  a 
thumb-forceps  and  the  handle  of  the  scalpel,  until  the  axillary  vein  is 
exposed  to  view.  With  this  the  most  important  step  of  the  operation  is 
accomplished.  Seeing  the  vein  will  jjrevent  its  accidental  injury,  and  from 
T7 


Fig.  100. — Eemoval  of  axillary  contents.     The  surgeon  lioldiug 
the  detached  breast  serving  as  a  handle. 


116 


RULES  OF   ASEPTIC  AND  ANTISEPTIC  SURGERY. 


this  on,  in  most  cases,  dissection  will  be  directed  aiuay  from  instead  of  toicard 
the  vein.    The  loose  fat  can  be  easily  detached  from  all  its  lateral  adhesions. 


Fig.  101. — Sutured  wouuJ  after  amputation  of  breu.-i.      i  vui.tcr-inoLsion  through  latissimus  for 

purposes  of  drainage. 

The  vessels  and  nerves  which  traverse  the  adipose  tissues  can  be  distinctly 
felt  and  seen  as  they  are  successively  approached.  If  necessary  the  long 
thoracic  artery  and  vein,  and  sometimes  the  subscapular  vessels,  should  be 


Fig.  102. — Completed  dressing  after  breast  amputation. 

taken  up  and  cut  between  two  forceps.  The  nerves  ought  to  be  preserved. 
During  the  dissection  of  the  axillary  contents,  the  breast  serves  as  a  suitable 
handle.  Breast  and  axillary  contents  are  removed  in  one  mass.  Thus  the 
intervening  lymphatic  ducts  are  certainly  taken  away  together  with  the 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.  117 

mammary  gland  and  the  axillary  lymphatic  glands.  After  due  irrigation, 
a  counter-incision  is  made  on  the  external  aspect  of  the  latissimus-dorsi 
muscle.  The  knife  should  divide  the  skin  and  fascia  only  ;  then  a  dressing- 
forceps  is  thrust  through  the  muscle  into  the  most  dependent  part  of  the 
axillary  wound,  when  it  is  made  to  grasp  the  end  of  a  stout  drainage-tube, 
which  is  drawn  out  through  the  counter-incision,  to  be  transfixed  with  a 
safety-pin  and  clipped  off  even  with  the  skin. 

After  this  the  pectoral  wound  is  united.  Lister's  button  suture,  or  a 
quilled  suture,  or  any  other  of  the  known  forms  of  retentive  suture,  is 
applied  to  relieve  tension.  After  another  irrigation,  the  fine  catgut  sutures 
of  coaptation  are  put  in  until  the  wound  is  closed.  The  wound  is  once 
more  flushed  out  with  mercuric  lotion,  and  is  covered  with  the  dressings, 
care  being  taken  to  make  them  the  thickest  about  where  the  drainage-tube 
issues  forth.  The  dressings  are  secured  by  roller-bandages,  and  the  arm  is 
either  included  in  the  turns  of  the  bandage,  the  ulna  first  being  well  padded, 
or,  being  left  out,  is  supported  by  an  extra  sling. 

Ordinarily,  the  dressings  are  changed  and  the  tube  is  removed  on  the 
fourth  day  after  the  operation,  when  the  retention  sutures  are  also  extracted 
should  they  not  have  been  absorbed  by  this  time.  A  smaller  dressing  secures 
the  parts  against  injury.  Five  days  later  another  change  of  dressings  may 
take  place,  when  the  drainage  opening  will  be  found  closed  by  a  plug  of 
granulations.  After  this  a  covering  of  cerate  or  lead  plaster,  with  a  little 
pad  of  cotton  secured  by  a  strip  of  adhesive  plaster,  will  be  all  that  is  neces- 
sary until  cicatrization  is  complete. 

It  is  remarkable  how  soon  the  arm  regains  its  power  of  abduction  in  cases 
that  remain  free  from  suj^puration. 

Of  seventy  operations  for  tumors  of  the  mammary  gland,  sixty-eight 
were  done  on  Avomen  mostly  past  middle  life  ;  two  were  performed  on  men. 
The  male  cases  were  as  follows  : 

Case  I.— A.  B.,  aged  seventeen.  Growing  adenoma  of  right  mammary  gland. 
August  4,  1883. — Extirpation  of  the  tumor  ;  axilla  was  not  interfered  with.  Uninter- 
rupted primary  union. 

Case  II. — George  Eckert,  blacksmith,  aged  sixty.  Large,  very  hard  epithelioma 
of  the  right  mammary  gland,  starting  from  the  nipple,  which  was  unrecognizable  in 
the  ulcerated  mass.  Axillary  glands  involved.  April  27,  1886. — Amputation  of  breast 
and  evacuation  of  axilla  at  the  German  Hospital.  Large  portions  of  skin  and  of  the 
pectoralis  major  and  minor  muscles  had  to  be  removed.  Primary  union  followed, 
except  where  the  skin  could  not  be  brought  together.     June  7th. — Discharged  cured. 

In  five  cases  of  adenoma  of  young  women,  the  tumor  alone  was  removed. 

In  five  instances  (Mary  Hauser,  adeno-cystoma  ;  Emma  Bockhold,  cysto- 
sarcoma ;  Albert  Baron,  adenoma  ;  Sarah  S. ,  cysto-adeno-fibroma ;  Frida 
Meissner,  adeno-fibroma),  the  mammary  gland  alone  was  amputated,  the 
axillary  space  remaining  intact. 

The  remaining  fifty-eight  cases  consisted  of  fifty-two  cancers,  five  sar- 
comata, and  one  instance  of  tuberculosis.  In  each  of  these  the  entire  breast 
and  all  the  axillary  contents  were  removed. 


lis  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

Cancer 53  cases. 

Sarcoma 6 

Adeuonia.   7 

Adeno-fibroiua 2 

Adeno-cvstoma 1  case. 

Tuberculosis 1 

Total 70  cases. 

Of  this  number^  sixty-one  times  healing  hy  primary  union  tvas  observed. 
Five  cases  suppurated  in  consequence  of  infection  of  one  or  another  kind 
at  the  time  of  the  operation ;  three  cases  healed  by  granulation,  as  it  was 
impossible  to  cover  the  defect  caused  by  the  operation.  A  fourth  granu- 
lating case  died  of  erysipelas,  contracted  outside  of  the  author's  care  (Julie 
Schmalz,  scirrhus)  while  the  wound  was  not  yet  healed. 

Of  the  cases  healed  by  primary  adhesion,  one  died  of  continuous  throm- 
bosis of  the  axillary  and  innominate  vein,  with  subsequent  embolism  of  the 
pulmonary  artery.  The  catastrophe  took  place  shortly  after  the  first  change 
of  dressings,  made  eight  days  after  the  operation. 

Case. — Clara  Halm,  spinster,  aged  tliirty-two.  Kovember  30^  1883. — Amputation 
of  left  breast,  with  evacuation  of  axilla  for  small-celled  adeno-carcinoina ;  suture;  no 
drainage.  Deceniber  Ufth. — First  change  of  dressings;  entire  wound  absolutely  healed. 
On  Christmas  eve  the  patient  was  selling  crockery  over  the  counter.  April  Jf,  1885. — 
Typical  amputation  of  right  breast  at  the  German  Hospital  for  the  same  affection, 
togetlier  with  excision  of  relapsing  cancer  in  the  shape  of  a  small  node  in  the  cicatrix 
of  the  left  side.  Patient  was  doing  excellently  till  April  12th,  when  the  first  dressings 
were  changed,  and  the  wound  was  found  faultlessly  healed.  Immediately  after  the 
dressings  were  completed,  the  patient  became  faint  and  cyanosed;  breathing  labored, 
pulse  scarcely  to  be  felt;  the  left  deep  jugular  vein  was  permanently  distended. 
Hydropericardium  and  hydrothorax  developed  with  oedema  of  both  arms,  and  the 
patient  died  April  20th,  sixteen  days  after  the  operation,  having  had  normal  and  later 
subnormal  temperatures  throughout.  Autopsy  revealed  continuous  tkromiosis  of  left 
axillary  and  anonyma  vein,  the  thrombus  extending  into  the  right  auricle  and  the 
pulmonary  artery ;  bilateral  hydrothorax,  hydropericardium,  and  a  hismorrhagic  in- 
farction of  the  connective  tissue  in  the  posterior  mediastinum. 

The  only  unusual  circumstance  that  attracted  the  author's  attention 
immediately  before  the  second  and  fatal  operation  was  the  fact  that,  a  hypo- 
dermic injection  of  morphia  being  administered,  extensive  ecchymosis  ap- 
peared shortly  afterward  at  the  site  of  the  injection,  suggesting  a  morhid 
alteration  of  the  patient's  vascular  system. 

Thrombosis  and  embolism  were  observed  in  another  case,  which,  how- 
ever, ended  in  cure. 

Case. — Mary  Lier,  school-teacher,  aged  fifty-seven.  Suffering  from  old  pulmonary 
emphysema  and  chronic  bronchitis.  Face  slightly  cyanosed.  Scirrhus  of  right  breast ; 
nipple  retracted,  discharging  dark,  tar-like  serum.  Xoi-ember  I4.  i575.  —  With  the  kind 
assistance  of  Dr.  F.  Lange.  amputation  of  right  breast  and  evacuation  of  the  axilla  were 
performed.  Anjesthesia  by  ether  was  very  bad.  Feverless  course  of  healing.  Kotem- 
ler  i9^A.— Drainage-tube  was  removed.  November  23d. — Apoplectiform  seizure,  fol- 
lowed by  aphasia  and  agraphy,  which,  however,  gradually  disappeared.  December 
29th. — The  wound  was  entirely  healed,  and  patient  could  again  speak  Bohemian,  her 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.        119 

mother-tongue.     Gradually  she  regained  her  German  and  English,  and  in  1882  the 
author  heard  from  her  as  being  able  to  write  again. 

One  of  the  suppurating  cases  died  of  acute  catan^hal  pneumonia  and 
carcinosis  of  the  lungs,  twenty-two  days  after  the  operation,  the  wound 
doing  well  at  the  time  under  process  of  granulation. 

Case. — Mary  Volkmer,  housewife,  aged  forty-seven.  Soft  adeno-cancer  of  both 
breasts,  the  large  tumor  of  the  left  mamma  causing  much  distress.  March  17,  1881. — 
At  the  German  Hospital,  amputation  of  left  breast  and  evacuation  of  the  axilla  were 
done.  Wound  was  united  in  part  only  on  account  of  extensive  loss  of  integument. 
Suppuration  of  axillary  space  followed,  but  the  fever  resulting  therefrom  subsided 
directly  after  drainage  was  re-established.  Nevertheless,  patient  appeared  to  be  very 
ill.  April  8th. — Catarrhal  pneumonia  set  in,  to  which  she  succumbed.  Afril  9th. — 
On  post-mortem  examination  general  carcinosis  of  lungs  and  liver  and  catarrhal 
pneumonia  were  found. 

In  computing  the  three  fatal  cases,  that  of  Julie  Schmalz,  who  died  of 
erysipelas  contracted  under  the  care  of  another  physician  before  perfect 
cicatrization  had  taken  jilace,  can  justly  be  excluded.  Accordingly,  of  the 
remaining  sixty-seven  cases,  two  died  directly  in  consequence  of  the  opera- 
tion ;  none,  however,  on  account  of  septic  processes  established  in  the  wound. 
Thus,  the  author's  rate  of  mortality  from  accidental  wound  infection  in 
amputation  of  the  breast  would  be  0  ;  from  other  causes  beyond  the  influ- 
ence of  the  surgeon,  a  trifle  less  than  three  per  cent  (2 '98). 

XI.     ABDOMINAL   OPERATIONS. 

1.    General  Remarhs. 

The  relation  of  aseptics  to  the  surgical  treatment  of  the  peritoneal  cavity 
is  in  some  quarters  a  subject  of  hot  controversy  to  this  day.  On  one  side 
we  see  the  advocates  of  a  more  or  less  complicated  antiseptic  apparatus, 
including  the  spray,  achieving  very  good  results,  and  basing  success  upon 
the  strict  enforcement  of  their  cautelse.  But,  on  the  other  hand,  we  notice 
a  most  successful  laparotomist  maintaining  that  antiseptics  are  unnecessary, 
or  even  harmful,  and  that  he  is  accustomed  to  flush  the  peritoneal  cavity 
with  "  water  from  the  tap,"  teeming  with  millions  of  bacteria,  and  yet  his 
results  vie  with  those  of  the  most  scrupulous  Listerian.  Both  sides  to  the 
controversy  have  abundant  and  incontrovertible  facts  to  support  their  posi- 
tions, and  the  contradiction  seems  to  be  hopelessly  insurmountable.  It 
certainly  is  extremely  bewildering  to  the  student  and  beginner.  Yet  this 
contradiction  is  unreal,  and  let  us  say,  on  one  side,  also  disingenuous. 

The  physiological  peculiarities  of  the  peritonaeum,  most  notably  its  enor- 
mous absorbent  power,  endow  it  with  the  quality  of  neutralizing  the  deleteri- 
ous effects  of  limited  quantities  of  pyogenic  or  septic  micro-organisms — a  qual- 
ity not  possessed  to  such  an  extent  by  any  other  part  of  the  human  organism. 

Grawitz*  has  brought  experimental  proof  of  the  fact  that  the  normal 
peritonaeum  will  at  once  absorb  into  the  circulation  moderate  quantities  of 

*  "  Charite  Annalen,"  xi.  Jahrg.,  page  770. 


120  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SUEGERY. 

active  pyogenic  cocci,  where  they  will  be  widely  scattered  through  the  blood 
and  perish. 

Note. — This  fact  goes  very  far  to  explaia  Lawson  Tail's  position,  who,  however,  although 
disclaiming  antiseptics,  devotes  most  scrupulous  care  to  asepticism — that  is,  to  the  cleansing  of 
hands  and  instruments.  His  instruments  are  few,  and  selected  with  a  view  to  simplicity.  His 
sponges  are  put  into  carbolic  lotion  for  disinfection.  The  water  used  for  the  immersion  of  his 
instruments  is  sterilized  by  boiling.  Most  of  the  bacteria  contained  in  his  "  water  from  the 
tap  "  are  innocuous — that  is,  non-pyogenic :  and  those  that  have  the  power  to  cause  suppuration 
are  too  few  to  produce  serious  trouble.  They  are  simply  absorbed  and  killed  off  by  the  great 
germicide,  the  blood. 

The  limit  of  the  quantity  of  pyogenic  cocci  required  to  produce  acute 
purulent  peritonitis  varies  with  the  size  and  state  of  health  of  the  animal 
used  in  the  experiment.  A  large  dog's  peritomeum  would  resist  a  much 
greater  quantity  of  infectious  pus  than  that  of  a  small  dog  or  rabbit.  And 
a  healthy  animal  would  neutralize  more  septic  material  than  a  debilitated 
one  of  the  same  kind  and  weight. 

The  presence  in  the  peritoneal  cavity  of  a  larger  quantity  of  stagnant 
bloody  serum  than  can  be  readily  absorbed  within  an  hour,  will  suffice  to 
produce  purulent  peritonitis  on  the  addition  of  a  very  small  number  of  cocci. 

If  the  fluid  is  absorbed  or  artificially  removed  by  drainage  before  the 
cocci  have  a  chance  to  vastly  multiply,  no  peritonitis  or  only  adhesive  forms 
of  the  inflammation  will  develop. 

Therefore,  it  is  rational  to  employ  drainage  in  cases  wliere  large  sur- 
faces, denuded  of  peritonseum,  have  to  be  left  behind  in  the  abdomen. 

Denudation  of  the  surface  layer  of  the  peritoneal  endothelium  by  caloric, 
or  mechanical  or  chemical  influences,  is  the  main  factor  in  causing  the  de- 
velojnnent  of  purulent  peritonitis.  It  favors  exudation  of  serum  and  dimin- 
ishes or  destroys  the  power  of  absorption  inherent  to  the  normal  peritonaeum. 
Should  even  a  minute  quantity  of  pyogenic  cocci  be  introduced  into  the 
peritoneal  cavity  under  these  circumstances,  purulent  peritonitis  may  readily 
develop. 

The  practical  conclusions  to  be  drawn  from  the  preceding  facts  are  : 

1.  Although  the  normal  peritonaeum  will  tolerate  a  greater  quantity  of 
infectious  material  than  most  surgical  wounds,  yet  all  precautions  regarding 
the  cleansing  of  hands,  instruments,  sponges,  and  other  apparatus  used  for 
laparotomy  should  be  employed,  as  septic  infection  of  the  peritonaeum  is 
much  easier  to  prevent  than  to  cure. 

2.  Unnecessary  denudation  of  tlie  uppermost  layer  of  the  peritonaeum 
should  be  avoided  as  much  as  possible. 

3.  Corrosive  solutions,  as,  for  instance,  of  carbolic  acid  or  mercuric  bi- 
chloride, are  not  to  be  used  on  the  peritonaeum.  As  soon  as  the  peritoneal 
cavity  is  opened,  Thiersch's  solution  should  be  employed  for  rinsing  the 
surgeon's  hands,  immersing  the  instruments,  sponges,  towels,  and,  if  neces- 
sary, for  irrigation. 

4.  A  careful  toilet,  that  is,  removal  of  all  exuded  serum  or  blood,  should 
precede  closure  of  the  abdominal  wound. 

5.  Where  large  denuded  surfaces  have  to  be  left  behind,  and  a  good  deal 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.        121 

of  oozing  is  to  be  exjDected,  drainage,  or  plugging  with  strips  of  iodoform 
gauze,  or  both,  must  be  employed. 

Note. — If  the  drain-tube  is  brought  out  from  a  dependent  part  of  the  peritoneal  cavity,  as 
for  instance  through  Douglas's  cul-de-sac,  the  secretions  will  escape  spontaneously  by  the  opera- 
tion of  the  law  of  gravity.  Whenever  the  di-ainage-tube  is  brought  out  above  the  symphysis, 
the  serum  collecting  at  the  bottom  of  the  cavity  must  be  removed  either  by  hourly  mopping  out 
with  a  stick,  armed  with  a  pad  of  absorbent  borated  cotton,  or  by  exhausting  with  a  long-nozzled 
syringe,  introduced  to  the  bottom  through  the  hollow  of  the  drain-tube. 

6.  Should  it  become  evident  that  the  mode  of  drainage  employed  is  insuffi- 
cient to  remove  a  copious  gathering  of  secretions,  febrile  symptoms,  tender- 
ness, and  tympanites  developing  on  the  first  few  days  after  the  operation,  a 
saline  purge  may  be  employed  in  preference  to  the  accustomed  opium  treat- 
ment (Tait).  Its  object  would  be  to  favor  rapid  absorption  of  the  effused 
serum  in  an  analogous  manner  seen  with  the  administration  of  cathartics  for 
the  rapid  removal  of  hydropic  accumulations  from  the  abdominal  cavity. 

7.  If  purulent  j)eritonitis  be  undoubtedly  established,  reopening  and  irri- 
gation of  the  i^eritoneal  cavity  with  hot  Thiersch's  solution  may  be  taken  into 
consideration,  jirovided  that  the  patient's  general  condition  should  warrant 
such  a  procedure. 

2.  Herniotomy. 

In  the  main,  the  success  of  herniotomy  depends  upon  the  condition  of 
the  strangulated  gut  at  the  time  of  the  operation.  With  aseptic  jDrecau- 
tions,  as  long  as  the  gut  is  not  necrosed,  herniotom}^  is  fraught  with  very 
little  danger.  From  the  moment  that  intestinal  gangrene  has  set  in,  the 
preservation  of  asej)ticism  becomes  extremely  difficult.  Contact  alone  with 
the  decayed  gut  is  infectious.  Laceration  of  the  friable  intestinal  wall  is 
very  likely  to  occur  on  employment  of  the  least  amount  of  force,  and  usually 
leads  to  further  contamination  by  escaping  intestinal  contents.  In  addition 
to  this,  the  general  condition  of  patients  with  intestinal  necrosis  is  mostly 
wretched.  Systemic  intoxication,  and  the  tendency  to  heart-failure  induced 
by  constant  vomiting,  vastly  increase  the  perils  of  anaesthesia  and  hgemor- 
rhage,  and  the  prognosis  is  thereby  rendered  all  the  more  doubtful. 

The  free  exhibition  of  anodynes,  especially  in  the  shape  of  hypodermic 
injections,  in  the  presence  of  strangulated  hernia,  is  very  often  followed  by 
fatal  consequences.  The  most  acute  symptoms  are  blurred  or  blotted  out 
entirely,  and  a  false  sense  of  security  is  a^tt  to  lull  the  apiyreliensions,  and 
to  betray  patient  and  physician  into  undue  j)rocrastination. 

Out  of  the  fifty-one  cases  of  herniotomy  performed  by  the  author  both 
for  strangulation  and  for  the  radical  cure  of  the  complaint,  eleven  died. 
Eight  out  of  this  number  exhibited  necrosis  of  the  gut,  and  all  of  these  died. 
Of  the  remaining  three,  one,  whose  gut  was  sound,  died  of  acute  nephritis, 
presumably  due  to  the  use  of  ether  as  an  angesthetic  ;  the  other  one  of  gen- 
eral tuberculosis  of  the  peritonaeum  ;  the  third  of  acute  sepsis  due  to  para- 
lytic distention  of  the  gut  induced  by  peritonitis. 

Case  I. — A.  Schlesinger,  aged  seventy-three,  strangulated  left  inguinal  hernia  of 
twenty-four  hours'  standing.    April  13,  1885. — At  Mount  Sinai  Hospital,  the  hernial  sac 


122  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

was  exposed  under  ether  anaesthesia.  A  knuckle  of  gut  could  be  felt  within  the  sac,  con- 
taining a  cubic,  friable  body  that  was  easily  crushed,  whereupon  the  gut  was  replaced 
in  the  abdominal  cavity  without  any  difficulty.  The  wound  was  sutured  and  dressed. 
Duration  of  the  operation,  twenty  minutes.  The  wound  liealed  by  ])riraary  adhesion, 
but  urpemic  symptoms,  with  suppression  of  the  renal  secretion  and  vomiting,  developed 
on  the  second  day.  The  scanty  urine  was  found  containing  blood  and  a  large  amount 
of  albumen.     April  22d. — The  patient  died  in  uraemic  coma. 

Inquiry  elicited  the  fact  that,  preceding  the  day  of  the  patient's  illness, 
he  had  largely  consumed  of  a  dish  of  potato  soup.  The  toothless  old  man 
had  bolted  some  of  the  potato,  a  piece  of  which  having  made  its  way  into 
the  hernia  caused  strangulation. 

The  other  fatal  case,  not  due  to  necrosis  of  the  gut,  was  as  follows  : 

Case  II. — Mrs.  Henrietta  Bolz,  housewife,  aged  sixty,  an  ill-nourished,  emaciated 
person,  who  said  that  she  had  been  suffering  from  belly-ache  and  constipation  for  two 
months,  and  that  she  has  had  severe  and  continuous  fever  that  caused  her  present 
emaciation.  She  also  noted  that  she  had  lost  most  of  her  hair.  Forty-eight  hours  pre- 
vious to  her  admission,  irreducible  femoral  hernia  of  the  right  side  was  diagnosticated 
by  a  medical  man.  Vomiting,  no  fever,  and  great  tenderness  over  the  abdomen  were 
found,  and  it  was  deemed  proper  to  explore  the  hernia.  Accordingly  the  operation 
was  done,  May  7,  1887,  at  the  German  Hospital.  After  incision  of  the  sac,  this  was 
found  to  contain  a  portion  of  adherent  omentum,  together  with  a  very  much  congested 
knuckle  of  small  gut.  The  strangulating  band  was  incised,  the  gut  withdrawn,  and, 
being  in  a  viable  condition,  was  replaced.  The  protruding  portion  of  omentum  was 
liberated,  tied,  and  cut  off.  In  replacing  it,  extensive  adhesions  of  the  stump  to  the 
parietal  peritonaeum  could  be  felt  inside  of  the  abdominal  cavity.  The  sac  was  excised 
and  tiie  wound  closed  and  dressed  in  the  usual  manner.  May  12th. — Change  of  dressings. 
The  wound  was  found  united,  but  the  general  condition  of  the  patient  had  remained 
the  same  as  before  the  operation.  Gradually  considerable  ascites  developed,  the 
patient  continuing  to  complain  of  much  colicky  pain  ;  the  vomiting  and  lack  of  appetite, 
together  with  rebellious  constipation,  seemed  to  justify  the  assumption  of  a  general 
morbid  condition  of  the  peritoneum,  namely,  either  tuberculosis  or  a  neoplasm.  May 
26th. — The  peritoneal  cavity  was  reopened  at  the  site  of  the  cicatrix  left  by  herniotomy, 
and  extensive  tubercular  degeneration  of  the  entire  peritonaeum,  with  dense  infiltration 
of  the  omentum  and  almost  universal  agglutination  of  the  intestines,  were  found.  The 
parietal  peritonaeum  and  the  gut  were  literally  covered  with  a  mass  of  miliary  white 
nodules.  With  a  view  to  relieving  the  obstruction  caused  by  the  multiple  adherence 
of  the  bowels,  a  protruding  part  of  the  thick  gut  was  attached  to  the  wound  by  a 
number  of  catgut  stitches,  and  the  external  incision  was  packed  with  iodoformized 
gauze.  May  28th. — The  bowel  was  found  well  united  with  the  parietal  peritonaeum,  and 
an  artificial  anus  was  established  by  incising  the  gut  and  sewing  the  mucous  membrane 
to  the  skin.     Sufficient  stools  followed,  but  the  patient  died,  March  31st,  of  exhaustion. 

Case  III. — I.  F.,  jeweler,  aged  fifty-four.  Strangulated  ventral  hernia  of  large 
proportions  in  a  very  obese  subject.  July  i,  1887. — Laparotomy  in  the  patient's  home. 
Several  feet  of  very  much  congested  and  extremely  dihited  small  intestine  were  replaced 
with  much  difficulty.  The  edges  of  the  hiatus,  located  just  above  the  umbilicus,  were 
pared,  and  closed  with  eight  button-sutures.  Duration  of  the  operation,  two  hours. 
Patient  did  not  rally  well,  continuing  to  moan  and  to  vomit  bilious  matter.  The  temper- 
ature rose  to  104°  Fahr.  during  the  night,  and  the  man  died  under  symptoms  of  intense 
sepsis  and  peritonitis  twenty  hours  after  the  operation.     Some  peritonitis  was  present 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD. 


123 


at  the  time  of  the  herniotomy,  and  might  have  been  stimuhited  by  the  operation,  which, 
however,  was  clearly  obligatory.     No  autopsy. 

Forty  (including  those  subjected  to  the  radical  operation)  of  the  author's 
total  fifty-one  herniotomized  patients  recovered. 

a.  Herniotomy  for  Strangulation. — If  gentle  and  not  too  prolonged 
efforts  at  reduction,  first  without  then  with  anaesthesia,  do  not  succeed, 
herniotomy  should  be  done  forthwith.    The  mode  of  procedure  is  as  follows : 

If  fecal  vomiting  be  observed,  it  is  advisable  to  wash  out  the  stomach  with  an  oesophageal 
tube,  to  prevent  the  entrance  of  fecal  matter  into  the  air-passages  during  anaesthesia. 

The  jiatient's  inguinal  region  is  shaved  and  scrubbed  off 
with  soap  and  hot  water,  and  is  disinfected  with  mercuric 
lotion.  Towels  wrung  out  of  corrosive-sublimate  solution  are 
arranged  about  the  field  of  operation,  and  a  free  incision  is 
made  over  the  hernial  swelling  down  upon  the  sac.  The  in- 
cision should  extend 


Fig.  103. — Patient  ready  for  herniotomy  (or  for  any  otlier 
operation  about  the  genital  region). 


well  above  the  itigui- 
nal  or  femoral  ring, 
and  should  freely  ex- 
pose the  place  where 
the  hernia  emerges 
from  the  aMominal 
ivall.  By  doing  this 
the  surgeon  will  be 
enabled  to  divide  the 
constricting  band  un- 
der the  guidance  of 
the  eye,  and  without 
the  necessity  of  in- 
serting the  probe-pointed  knife  into  the  inguinal  or  femoral  canal,  a  cir- 
cumstance that  may,  even  in  the  hands  of  a  cautious  and  expert  surgeon, 
lead  to  cutting  or  laceration  of  the  intestine,  especially  if  it  be  very  brittle, 
or  necrosed,  or  adherent. 

Case  IV. — Philip  Tramann,  aged  two  years  and  three  months,  was  presented  to 
the  author  December  11,  1881,  with  a  soft,  fluctuating,  scrotal  swelling  of  the  left  side, 
which,  however,  could  not  be  by  pressure  reduced  in  size.  Congenital  hydrocele  was 
diagnosticated  nevertheless,  as  the  tumor  showed  transparency.  Puncture  with  a 
hypodermic  needle  brought  out  intestinal  contents.  There  were  no  signs  of  strangula- 
tion, therefore  cold  applications  were  ordered,  and  the  child's  mother  was  told  to  return 
the  next  day.  By  December  12th  all  symptoms  of  strangulation,  with  rather  high 
fever  and  inflammation  of  the  swelling,  had  developed.  Herniotomy  was  done  at  the 
German  Dispensary.  In  opening  the  sac,  the  gut  was  inadvertently  incised.  It  was 
found  that  local  peritonitis  of  the  sac,  with  extensive  fresh  adhesions,  presumably  due 
to  escape  of  fecal  matter  through  the  puncture-hole,  had  taken  place.  The  gut  was 
detached  everywhere  by  the  finger-tips,  the  parts  were  well  disinfected  by  free  irriga- 
tion with  a  two-per-cent  solution  of  carbolic  acid,  and  the  slit  in  the  intestine  was 
closed  with  a  Lembert  suture  of  catgut.  The  strangulating  band  was  then  cut,  and, 
the  intestine  being  replaced,  the  wound  was  sewed  up,  drained,  and  dressed.  Un- 
18 


lL^-4 


RULES  OF  ASEPTIC  AND   ANTISEPTIC  SURGERY. 


f'lL..  iL'i. — ilerniotomy.     Cutaneous  incisiou. 


interrupted    recovery    followed.      January   12,    lS82.—The    patient    was    discharged 
cured. 

The  sac  is  carefully  opened  between  two  forceps,  and,  if  possible,  at  a 
place  where  there  is  no  adhesion  to  the  gut.     After  free  division  between 

two  thumb -forceps, 
a  careful  inspection 
of  its  contents,  gut 
or  omentum,  or  both, 
should  be  made.  This 
will  be  very  much 
facilitated  by  taking 
up  the  edges  of  the 
incision  made  into 
the  sac  with  a  num- 
ber of  artery  forceps, 
which  will  serve  as 
handles  to  unfold  it 
to  a  funnel,  which 
can  be  easily  looked 
over.  (Fig.  105.) 
Generally  the  gut  will  appear  deeply  congested,  purplish,  or  brownish 
red.  As  long  as  it  is  turgid,  and  is  seen  to  contract  on  pinching,  it  may 
be  assumed  to  be  viable. 

But  it  still  remains  to  be  ascertained  whether  the  points  of  strangulation 
be  alive  or  not.  To 
do  this  the  strangu- 
lating hand  or  hands 
mnst  he  first  cut  to  a 
sufficient  extent. 

Attempts  to  with- 
draw the  gut  before 
the  strangulation  is 
completely  removed 
may  lead  to  very  seri- 
ous consequences,  es- 
pecially w^here  necro- 
sis of  the  strangulated 
portion  of  the  intes- 
tine is  present. 

Case  V. — J.  Schrank, 
saloon-keeper,  aged  fifty- 
nine.  Left  inguinal  stran- 
gulated hernia  of  five  days'  standing.    Herniotomy,  March  8,  1886,  at  the  German  Hos- 
pital.    The  sac  contained  a  large  mass  of  adhering  omentum,  and  a  knuckle  of  deeply 
congested  small  intestine.     It  was  thought  that  the  strangulating  band,  corresponding 
to  the  internal  abdominal  ring,  had  been  sufficiently  incised,  and  a  very  gentle  and 


Fig.  lO.J.— Ilenuotomy.     The  opened  hernial  sac  is  held  apart 
for  inspection  by  a  number  of  artery  forceps. 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.         125 

unsuccessful  attempt  was  made  to  withdraw  the  gut.  The  tip  of  the  index  was  rein- 
serted as  a  guide,  and,  the  constriction  being  completely  divided,  the  gut  was  easily- 
withdrawn.  At  the  same  moment  a  considerable  quantity  of  fecal  matter  was  seen  to 
escape.  It  was  found  that  necrosis  of  the  neck  of  the  strangulated  knuckle  of  gut  had 
taken  place,  and  that  it  had  been  torn  or  cut  during  the  preceding  efforts  at  liberation. 
The  intestine  was  still  further  extracted,  and  was  attached  to  the  skin  by  a  few  silk 
sutures.  After  careful  disinfection,  the  neck  of  the  sac  was  loosely  packed  with  strips 
of  iodoformized  gauze,  and  the  wound  was  inclosed  in  a  moist  dressing.  The  collapsed 
patient  died  two  hours  after  the  operation. 

In  cases  like  the  preceding  one,  the  classical  practice  of  invaginating  the 
tip  of  the  index  into  the  inguinal  canal  or  femoral  ring,  for  the  j^nrpose 
of  cutting  the  strangulating  band,  is  dangerous,  as  it  may  lead  to  injury  of 
the  brittle  gut. 

The  author  has  found  the  gradual  division  of  all  tissues  from  without 
inward  much  safer,  although  it  must  be  admitted  that  the  division  of  the 
fibrous  tissues  located  above  the  place  of  strangulation  is  extensive,  and  often 
practically  converts  herniotomy  into  laparotomy. 

With  a  few  exceptions,  the  author  has  always  employed  025en  division 
of  the  strangulating  bands  of  tissue,  and  never  had  reason  to  regret  it.  In 
some  of  the  complicated  cases  he  was  thereby  enabled  to  at  once  gain  a  very 
clear  insight  into  the  relations  of  the  hernia,  and  in  a  great  measure  the 
ultimate  success  of  the  operation  was  attributed  to  that  advantage. 

Case  VI. — Fred.  Bormann,  laborer,  aged  thirty- three,  had  been  treated  at  the  Ger- 
man Hospital  without  success  during  several  days  for  internal  intestinal  obstruction 
marked  by  the  usual  symptoms.  On  closer  inspection,  slight  oedema  of  and  somewhat 
indistinct  resistance  at  the  right  inguinal  region  was  noted.  January  17,  1884- — An 
incision  was  made  exposing  the  external  inguinal  ring,  which  was  seen  to  be  normal. 
The  incision  was  further  extended,  and,  when  most  of  the  fibrous  layers  surrounding 
the  inguinal  canal  had  been  divided,  a  small  but  well-defined  tumor  could  be  seen  and 
felt  occupying  the  inner  aspect  of  the  abdominal  wall  near  the  internal  orifice  of  the 
inguinal  canal.  The  abdominal  wall  was  completely  divided,  and  then  a  small  hernia, 
located  between  the  parietal  peritonaeum  and  the  abdominal  wall,  was  exposed.  The 
sac  being  incised,  a  knuckle  of  small  gut  was  found  contained  within  it.  The  place  of 
strangulation  was  at  the  neck  of  the  sac.  This  was  completely  slit  open,  the  gut  was 
reduced,  and,  the  neck  of  the  sac  being  closed  by  a  purse-string  ligature,  it  was  cut 
away  entirely.  The  incision  in  the  abdominal  wall  was  closed  by  three  tiers  of  catgut 
sutures.     Primary  union  followed.     February  16th. — Patient  was  discharged  cured. 

Case  VII. — Mr.  M.  S.,  aged  thirty-six.  Left  inguinal  hernia,  that  had  been  repeat- 
edly incarcerated,  but  was  reduced  each  time.  April  8,  1885,  it  came  down  again, 
and,  after  prolonged  and  very  energetic  efforts,  the  physician  in  charge  succeeded  in 
replacing  it,  but  the  symptoms  of  strangulation,  notably  vomiting  and  absence  of  alvine 
evacuations,  persisted.  April  12t7i. — Herniotomy  at  Mount  Sinai  Hospital.  jSTo  ex- 
ternal tumor  could  be  seen,  but  on  palpation  a  dense  resistant  swelling  could  be  felt 
in  the  inguinal  region  within  the  abdominal  wall.  The  region  of  the  external  abdom- 
inal ring  was  freely  exposed  by  an  ample  incision,  and  the  abdominal  wall  was  divided 
above  Poupart's  ligament.  The  hernia  which  had  been  reduced  in  mass  was  then 
reached,  and  was  pushed  out  through  the  inguinal  canal.  The  remaining  portion  of 
the  intervening  abdominal  wall  was  divided,  together  with  the  place  of  strangulation. 


126  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

and,  the  sac  being  tied  and  cut  away,  the  abdominal  wound  was  closed  with  three 
tiers  of  strong  catgut  sutures.  The  wound  healed  kindly.  May  15th. — Patient  was 
discharged  cured. 

It  may  be  said,  then,  that  open  division  offers  great  advantages,  espe- 
cially with  regard  to  the  avoidance  of  injury  to  necrosed  or  very  brittle  gut, 
and  that  its  only  drawback — the  increased  size  of  the  incision — is  vastly 
overbalanced  by  the  security  gained  therefrom.  If  the  gut  be  found  ne- 
crosed, it  can  be  safely  withdrawn  from  the  ample  aperture,  and  establish- 
ment of  an  artificial  anus  can  take  place  after  securely  packing  the  neck  of 
the  protruding  knuckle  of  intestine  with  a  sort  of  embankment  of  iodo- 
formized  gauze.  This  packing  of  gauze  serves  as  a  diaphragm  against  infec- 
tion of  the  peritoneal  cavity. 

Out  of  twenty-four  cases  of  herniotomy  done  for  strangulation,  undoubt- 
ed gangrene  of  the  gut  was  present  at  the  time  of  operation  in  six.  In 
two  of  these  the  necrosed  part  of  the  gut  was  injured  within  the  inguinal 
canal  by  the  unavoidable  manipulations  in  liberating  the  intestine.  In 
those  cases  where  external  or  open  section  was  used,  the  integrity  of  the 
much-decayed  gut  was  preserved.  In  these  latter  cases  the  gangrene  ex- 
tended to  the  free  part  of  the  gut,  and  was  taken  notice  of  before  dissolving 
the  strangulation.  In  the  former  cases,  however,  in  which  the  gut  was 
inadvertently  injured,  gangrene  was  limited  to  the  exact  locality  of  the  con- 
striction, and  was  diagnosticated  only  after  the  mishap. 

The  practical  lesson  to  be  drawn  from  this  experience  is  that  open  incis- 
ion of  the  inguinal  canal  should  be  done  whenever  very  acute  strangulation 
has  exi.sted  for  more  than  four  or  six  hours. 

All  the  patients  upon  whom  necrosed  gut  was  found  died  either  of  col- 
lapse, shortly  after  the  completion  of  the  operation,  or  of  peritonitis  due 
to  infection  extending  from  the  place  of  strangulation. 

On  one  of  them  resection  of  the  necrosed  part  of  the  gut  was  practiced, 
with  subsequent  suture.     The  i:)atient  died  of  peritonitis. 

Case  Vlll. — Catharine  Ihle,  housewife,  aged  sixty-one,  a  very  fat  woman,  having 
a  large  incarcerated  umbilical  hernia,  was  operated  September  24,  1881,  at  her  rooms 
in  the  presence  of  the  family  attendant,  Dr.  Arcularius.  Open  section  of  constricting 
bands,  circumscribed  necrosis  of  the  neck  of  the  protruding  mass  of  transverse  colon. 
Exsection  of  sis  inches  of  thick  gut  and  of  a  triangular  piece  of  meso-colon,  and  sub- 
sequent enterorrhaphy  with  fine  catgut ;  closure  of  abdominal  cavity.  Peritonitis 
developed  during  the  following  night,  and,  September  25tb,  patient  died  with  enormous 
tympanites. 

Immediate  exsection  of  the  necrosed  gut  has  little  to  commend  it.  The 
dangers  of  infection  of  the  peritonaeum  are  almost  insurmountable,  the  com- 
prehensive preparations  required  for  enterorrhaphy  are  usually  not  made, 
and,  the  work  being  extemporized,  generally  lacks  exactitude.  In  addition 
to  this,  the  general  condition  of  the  patients  is  commonly  so  bad,  that  undue 
prolongation  of  anaesthesia  itself  would  be  very  dangerous.  Therefore,  in 
these  cases,  the  establishment  of  an  artificial  anus  is  the  proper  thing  to  do. 
(See  Enterorrhaphy,  page  158.) 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.        127 

To  young  physicians  the  decision  of  the  question,  whether  the  gut 
be  alive  or  necrosed,  may  offer  a  good  deal  of  difficulty.  The  responsi- 
bility is  great,  and  uncertainty  about  a  point  of  such  importance  extremely 
perplexing.  Where  necrosis  is  fairly  established,  the  shriveled,  parchment- 
like ajDpearance,  the  yellowish-gray  color,  the  absence  of  reflex  motion  on 
pinching,  and  the  great  fragility  will  at  once  characterize  the  condition. 
But  v/here  necrosis  is  just  developing — that  is,  where  thrombosis  of  the 
terminal  vessels  with  bloody  infarction  has  gone  so  far  as  to  surely  com- 
promise the  integrity  of  the  gut,  but  the  signs  of  necrosis  are  as  yet  unrec- 
ognizable— decision  may  be  very  difficult  indeed. 

The  causes  producing  intestinal  necrosis  are  not  identical  in  different 
cases.  Local,  well-circumscribed  necrosis,  limited  to  the  extent  of  the 
strangulating  ring,  and  very  often  found  in  femoral  hernia,  is  due  to  local 
anaemia  produced  by  the  pressure  of  the  constricting  band. 

In  other  cases  the  local  pressure  exerted  by  the  constricting  band  upon 
the  neck  of  the  hernial  contents  may  be  insufficient  to  destroy  the  vitality 
of  the  intestine  in  actual  contact  with  the  constricting  tissues.  But  press- 
ure that  would  be  hardly  sufficient  to  cnt  off  arterial  supply,  will  often  com- 
press to  such  an  extent  the  veins  leading  aiuay  from  the  strangulated  gut 
as  to  completely  arrest  circulation.  Venous  engorgement  and  gangrene 
of  the  convex  portion  of  the  intestinal  knuckle  are  then  inevitable. 

The  decision  whether  a  portion  of  intestine,  subjected  to  prolonged  acute 
anaemia  by  local  j^ressure,  is  viable  or  not,  is  comparatively  easy.  In  many 
of  these  cases,  absent  circulation  is  often  restored  to  the  bloodless  parts  under 
the  eyes  of  the  surgeon.  As  soon  as  the  constriction  is  relieved,  minute  red 
streaks  are  seen  to  spring  up  across  the  formerly  pale,  bloodless  area  ;  they 
increase  in  number,  and  finally  the  ]3arts  in  question  assume  a  rosy  hue  and 
a  normal  appearance. 

Sometimes,  however,  recovery  of  circulation  is  tardy.  In  these  cases, 
after  amply  dividing  the  strangulating  band,  a  catgut  thread  should  be 
passed  through  the  mesentery  of  the  questionable  loop  of  intestine,  which 
then  should  be  temporarily  replaced  in  the  abdominal  cavity.  The  time 
required  for  restoring  the  circulation  of  the  gut  is  usefully  employed  in 
attending  to  such  other  procedures  as  may  be  indicated  under  the  circum- 
stances. Dissection  and  removal  of  adherent  omentum,  or  the  dissection 
of  the  hernial  sac,  will  thus  occupy  some  time,  by  the  end  of  which  the  loop 
of  intestine  can  be  withdrawn  from  the  belly  for  examination.  If  the  con- 
ditions be  found  satisfactory,  the  thread  should  be  removed,  and  tlie  opera- 
tion finished  in  the  usual  way. 

Case  IX.  —  Theresa  Wagenglast,  cigarmaker,  aged  thirty -nine,  contracted,  April 
11,  1887,  strangulation  of  a  femoral  hernia  of  old  standing,  situated  on  the  left 
side.  April  15th. — Admitted  to  German  Hospital  with  incessant  vomiting,  induced 
mainly  by  the  administration  of  calomel.  Immediate  herniotomy.  A  considerable 
portion  of  adherent  omentum  presented,  and  was  tied  off  in  several  portions  and 
removed.  After  this  a  very  small  knuckle  of  gut  became  visible,  which  showed  an 
anaemic  area  corresponding  to  the  locality  of  constriction.     Recovery  being  tardy,  a 


12S  RULES  OF  ASEPTIC    .\XD   ANTISEPTIC  SURGERY. 

thread  of  catgut  was  passed  through  the  mesentery,  and  the  knuckle  was  replaced  in 
the  abdomen  through  the  well-divided  femoral  ring.  In  the  mean  time  the  sac  was 
excised.  After  the  completion  of  this  step,  requiring  about  fifteen  minutes,  the  gut 
was  re-extracted  for  examination,  and  circulation  was  found  fully  re-established.  The 
gut  being  replaced,  the  neck  of  the  sac  was  closed  with  a  purse-string  suture,  and  was 
pushed  well  up  in  the  femoral  ring.  Drainage  and  suture  of  the  external  wound. 
April  15th. — The  drainage-tube  was  removed.  April  29th. — Patient  was  discharged 
cured. 

Where  impending  gangrene  from  venous  engorgement  is  to  be  feared, 
the  decision  is  generally  more  difficult  than  in  the  preceding  class  of  cases. 
"When  immediate  solving  of  the  momentous  question  is  impossible,  the 
benefit  of  the  doubt  should  always  belong  to  the  assumption  that  necrosis 
is  to  be  expected.  In  these  cases  the  neck  of  the  hernial  sac  should  be  well 
divided  to  secure  the  best  circulation  possible,  and  the  loop  of  gut  should 
be  so  attached  to  the  skin  by  a  couple  of  sutures  passed  through  the  mesen- 
tery as  to  leave  the  questionable  spots  exposed  to  view.  Tliorough  disin- 
fection by  wiping  with  sponges  wrung  out  of  Thiersch's  solution,  a  light 
packing  of  iodoformized  gauze  around  the  neck  of  the  knuckle,  and  a  moist 
aseptic  dressing  (the  gut  being  covered  by  a  protective  strip  of  rubber  tissue) 
should  be  applied.  If  the  gut  decay,  this  will  take  place  outside  of  the 
peritoneal  cavity.  Should  it  recover,  the  fact  will  be  manifest  within  one 
or  two  hours  after  the  operation.  The  gut  should  be  then  well  disinfected, 
liberated  by  gentle  manipulation  from  its  newly-assumed  j)osition,  and 
replaced  in  the  abdominal  cavity. 

Case  X  illustrates  the  consequences  of  the  replacement  of  the  gut  of 
doubtful  vitality.     It  was  the  authors  first  herniotomy. 

Case  X. — John  Philip  lores,  waiter,  aged  fifty-three.  Very  acute  strangulation 
of  twelve  hours'  standing  of  an  old,  right  inguinal  hernia.  October  27,  1878. — Herni- 
otomy in  presence  of  Dr.  L.  Bopp,  the  family  physician.  Two  knuckles  of  deeply- 
injected  small  intestine,  aggregating  to  the  length  of  ten  inches,  and  a  mass  of  dark- 
blue  omentum  were  found  in  the  sac.  But,  as  the  gut  seemed  to  be  turgid  and  viable, 
it  was  replaced.  The  omentum  was  pulled  out,  tied  and  cut  off,  and  the  stump  was 
replaced.  Septic  symptoms  set  in  immediately  after  the  operation,  with  high  fever 
and  very  great  debility.  October  39th. — Unmistakable  signs  of  peritonitis,  notably 
enormous  meteorism,  appeared.  The  restless  patient  disarranged  the  dressings  during 
his  tossing  in  bed,  and,  while  vomiting,  the  adhesions  of  the  wound  gave  way,  and 
a  large  loop  of  intestine  prolapsed.  Necrosis  of  a  portion  of  the  prolapsed  gut  was 
evident.  As  much  of  it  as  was  normal  was  replaced,  the  decayed  part  of  the 
gut  was  incised,  and  fixed  near  the  external  wound.  The  patient  died  shortly 
afterward. 

It  must  be  added  that,  according  to  then  prevailing  notions  (1878),  the 
sac  and  its  contents  were  washed  with  a  strong  solution  of  carbolic  acid 
(5  :  lUO)  before  the  gut  was  replaced.  Superficial  erosion  of  the  intestinal 
peritoneum  may  have  had  its  share  in  precij)itating  both  gangrene  and  -pen- 
tonitis. 

Xecrosis  of  the  vermiform  appendix  was  observed  by  the  author  once 
with  fatal  termination. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.        129 

Case  XI. — Henrietta  Bauland,  aged  forty-seven.  Right  femoral  liernia  of  forty- 
eiglit  hours'  standing.  Ajml  18,  I8S4. — Herniotomy  at  the  German  Hospitah  Vermi- 
form appendix  was  found  attached  hy  its  apex  to  the  side  of  the  sac  ;  a  knuckle  of 
small  intestine  was  embraced  m  the  loop  formed  by  the  vermiform  appendix,  and  then 
doubly  incarcerated.  Manipulation  was  very  difficult,  on  account  of  the  narrow  space 
and  the  complicated  state  of  things.  The  gut  was  slightly  torn,  but  no  intestinal  con- 
tents escaped.  Two  Lembert's  sutures  being  applied,  the  strangulation  at  the  neck  of 
the  sac  was  relieved  and  the  gut  was  liberated.  The  middle  part  of  the  vermiform 
ai^pendix  loas  found  necrosed,  and  a  ligature  being  applied  above  this  part,  the  appen- 
dix was  cut  away.  The  gut  was  returned.  The  patient  got  on  very  well  until  April 
25th,  when  perforative  peritonitis  developed.  April  21th. — Patient  died.  No  autopsy 
could  be  secured. 

Plowever  desirable  tliorougliness  and  deliberation  may  be  in  herniotomy, 
undue  prolongation  of  anaesthesia  is  an  evil  fraught  with  especial  danger  in 
cases  of  long-continued  strangulation,  on  account  of  the  cardiac  debility 
present.  When  the  patient's  yitality  has  been  much  lowered  by  continnous 
vomiting,  loss  of  sleep,  and  septic  fever,  even  a  brief  anaesthesia  may  be 
sufficient  to  precipitate  fatal  collapse.  Habitual  users  of  alcohol  and  obese 
individuals  are  very  poor  subjects  to  endure  anaesthesia  in  the  presence  of 
necrosis  of  the  gut. 

Case  XII. — Albert  P.,  drayman,  aged  thirty-five,  moderate  hut  steady  consumer  of 
beer  and  whisky.  Incarcerated  right  inguinal  hernia  of  seventy -five  hours'  duration. 
The  swelling  was  mistaken  for  acute  orchitis,  hernia  being  thought  of  by  the  family 
attendant  only  after  fecal  vomiting  had  set  in.  March,  19,  1887. — Herniotomy  at  the 
German  Hospital.  Extensive  gangrene  of  the  small  gut  was  found.  Ether  anaesthesia 
was  very  bad,  the  patient  struggling  all  the  while  during  the  operation.  If  ether  was 
crowded,  respiration  became  irregular,  the  face  pallid,  and  syncope  threatening.  Arti- 
ficial anus  was  established,  and  the  case  was  finished  with  all  possible  expedition,  anees- 
thesia  lasting  altogether  for  thirty  minutes.  Deep  collapse  following,  the  patient  did 
not  rally  in  spite  of  copious  hypodermic  stimulation,  and  he  died  two  hours  after  the 
completion  of  herniotomy. 

It  is  plausible  to  assume  that  in  similar  cases  herniotomy  performed  with 
the  aid  of  local  anesthesia  would  offer  better  chances  of  success  than  if  it 
be  done  in  general  ether  or  chloroform  narcosis 

One  of  the  eleven  fatal  cases  died  of  acute  septicaemia  induced  by  diph- 
theritic enteritis  of  the  strangulated  knuckle  of  gut. 

Case  XIII. — Charles  Etzler,  baker,  aged  thirty-five.  Very  acute  strangulation,  of 
fifty  hours'  standing,  of  an  old  right  inguinal  hernia.  The  patient  had  had  no  medical 
care  until  a  few  hours  before  his  admission  to  the  German  Hospital,  when  Dr.  H.  Kudlich 
was  called  in.  He  was  requested  to  stop  the  violent  fecal  vomiting  caused  by  a  very 
large  dose  of  Rochelle  salts  taken  in  the  morning  of  January  31,  1884.  Herniotomy  on 
the  evening  of  the  same  day.  The  large  scrotal  hernia  contained  a  good-sized  portion 
of  adherent  omentum  and  a  massive  conglomerate  of  several  knuckles  of  small  gut, 
bound  together  by  firm  cicatricial  adhesions  of  old  date.  Free  external  incision  of  the 
abdominal  wall  until  the  neck  of  the  hernial  sac  was  completely  divided.  The  gut 
looked  tolerably  well  preserved  and  was  replaced ;  the  omentum  was  freed  by  dissec- 
tion, and,  being  tied  off  in  several  portions,  was  cut  off.  The  stump  being  replaced,  the 
sac  was  tied  and  cut  off";  then  the  abdominal  wall  was  sutured  by  several  tiers  of 


130  RULES  OF   ASEPTIC  AND  ANTISEPTIC  SURGERY. 

strong  catgut  in  i)hysiologiciil  onk-r.  The  outer  wound  w.as  drained,  sewed,  and 
dressed  as  usual.  February  1st  passed  off  without  any  untoward  symptom,  the  vom- 
iting having  ceased  immediately  after  the  operation.  February  2d.— A.  severe  chill 
with  much  belly-ache  set  in,  but  no  meteorism  appeared  until  February  4th,  tlie 
thermometer  indicating  all  the  while  105°  Fahr.  The  patient's  condition  grew  steadily 
worse,  with  deep  coma,  jaundice,  and  petechial  patches  on  the  legs.  Felritary  5th.~ 
The  sutures  gave  way  during  a  vomiting  spell,  and  a  loop  of  healthy-looking  gut  pro- 
lapsed. It  was  not  replaced.  Shortly  after  the  patient  died.  Post-mortem  examina- 
tion revealed  a  slaty  discoloration  of  the  mentioned  bunch  of  coherent  gut,  which, 
being  incised,  appeared  to  be  covered  on  its  mucous  side  with  a  large  number  of  round 
and  confluent  whitish-gray  adherent  patches  of  membrane,  which  involved  the  intes- 
tinal wall  to  varying  depths,  some  of  them  being  visible  through  the  peritoneal  cover- 
ing.    No  peritonitis. 

In  Case  XIV  such  a  combination  of  unfavorable  conditions  was  encount- 
ered as  would  baffle  every  effort  of  the  most  careful  surgeon.  The  co- 
existence of  great  general  debility  from  chronic  nephritis  of  old  standing, 
with  necrosis  of  a  considerable  part  of  the  upper  portion  of  the  jejunum,  is 
fortunately  very  rare. 

Case  XIV. — Mary  Ilenneberg,  aged  thirty-five.  Strangulated  femoral  hernia  of 
four  days'  standing.  March  28,  1889. — Herniotomy  at  German  Hospital.  Necrosis  of 
small  intestine.  Establishment  of  artificial  anus.  Escape  of  sulphur-colored  faeces  of 
acid  odor.  Collapsed  condition  of  patient  rendered  idea  of  enterorrhaphy  impracti- 
cable. March  29th. — Examination  of  scanty  urine  revealed  the  presence  of  mucli  albu- 
min and  hyaline  casts.  Though  the  patient  rallied  from  the  anaesthesia,  and  no 
further  local  trouble  developed,  she  did  not  pick  up  strength,  which  was  mainly  attrib- 
uted to  the  high  location  of  the  intestinal  leak.  April  J^th. — An  attempt  was  made 
to  anaesthetize  the  patient  in  order  to  perform  enterorrhaphy,  but  she  collapsed  at  the 
beginning  of  anaesthesia  to  such  an  extent  that  the  idea  of  operating  had  to  be  aban- 
doned. On  April  15th  she  died  of  inanition.  On  post-mortem  examination  a  far-gone 
degeneration  of  both  kidneys  was  found. 

Case  XV.  — Chaic  Zuckermann,  aged  forty-eight.  Strangulated  right  inguinal 
hernia.  Fecal  vomiting  of  four  days'  standing.  Bad  general  condition  Herniotomy 
at  Mount  Sinai  Hospital.  January  14,  iS-90.— Necrosis  of  gut  and  part  of  sac.  Diffi- 
cult liberation  of  gut.  Artificial  anus  established.  Patient  died  of  collapse  eleven 
hours  after  operation. 

Eight  of  the  successful  operations  for  strangulation  were  done  on  in- 
guinal (one  preperitoneal,  Case  V),  five  on  femoral  hernige. 

Cured 13  patients. 

Died 11         " 

Total 24 

In  dividing  the  strangulating  band  in  femoral  hernia,  the  incision  should 
be  directed  inward  toward  Gimbernat's  ligament.  But,  where  the  space  is 
very  narrow  or  the  condition  of  the  gut  doubtful,  free  incision  of  the  fascia 
lata  parallel  to  the  large  vessels,  and  preparatory  exjjosure  of  the  femoral 
canal,  would  be  more  proper. 

To  incise  the  strano'ulating  bands  sufficiently  to  enable  the  surgeon  to 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.        131 


Fig.  106. — Purse-strincr  sut- 
ure, employed  for  occluding 
the  neck  of  the  hernial  sac. 


withdraw  additional  portions  of  gut  for  examination  does  not  insure  facile 
rejjosition  by  any  means ;  and  forcible  crowding  back  of  the  congested  and 
vulnerable  intestine  through  an  insuflSciently  wide  orifice  may  lead  to  its 
rupture.  Therefore,  the  dilatation  must  be  very  ample  to  permit  easy  re- 
position without  the  use  of  undue  force. 

As  long  as  the  sac  is  not  closed,  and  communication  is  open  with  the 
peritoneal  cavity,  irrigation  of  the  wound  must  stop,  otherwise  large  por- 
tions of  the  lotion  may  find  their  way  into  the 
abdomen.  The  use  of  strong  solutions  of  carbolic 
acid  or  mercuric  bichloride  on  the  prolapsed  gut 
is  not  advisable  and  is  unnecessary.  As  soon  as 
the  gut  is  replaced,  the  sac  should  be  wiped  clean 
with  a  disinfected  sponge,  and  another  small 
sponge,  fastened  to  a  thread  of  catgut,  should  be 
pushed  into  the  inguinal  canal  to  serve  as  a  bar- 
rier to  the  influx  of  blood  into  the  peritoneal  cav- 
ity. If  the  patient  is  seen  to  bear  anaesthesia 
well,  inguinal  herniotomy  can  be  supplemented 

by  the  addition  of  the  suture  of  the  inguinal  canal,  as  described  under 
the  heading  of  "Eadical  Operation  of  Hernia." 

Should,  however,  collapse  be  present  or  imminent,  and  prolongation  of 
anaesthesia  inadvisable,  a  thread  of  strong  catgut  is  passed  through  the 
neck  of  the  sac  (see  cut)  as  high  up  as  possible,  assistants  holding  well  apart 
the  artery  forceps  by  which  the  edges  of  the  cut  through  the  sac  are  se- 
cured.    This  suture  resembles  a  purse-string  in  its  workings  (Fig.  106). 

It  is  tightened  and  knotted,  and 
will  securely  occlude  the  perito- 
neal cavity.  Then  the  external 
wound  is  well  irrigated  with  cor- 
rosive-sublimate lotion,  a  drain- 
age-tube is  placed  well  up  to 
the  purse- string  suture,  and  the 
edges  of  the  skin  are  brought 
together  with  catgut  stitches. 
The  dry  dressings  are  applied  so 
as  to  cover  up  the  scrotum  and 
both  inguinal  regions,  a  slit  be- 
ing left  in  the  middle  for  the 
penis,  which  should  protrude 
from  the  bandages.  The  use  of 
a  "hip-rest"  will  facilitate  the 
application  of  the  otherwise  dif- 
ficult dressing.  In  private  practice,  a  common  hassock  or  footstool, 
wrapped  in  a  clean  towel  or  slipped  into  a  clean  pillow-case,  will  make  a 
capital  hip-rest. 

In  female  patients  the  compresses  are  held  down  by  a  spica  bandage. 
19 


Fig.  107. — Herniotomy.     Suture  of  external  wound. 


132 


RULES  OF  ASEPTIC  AND   ANTISEPTIC  SURGERY. 


Fig.  108. — Volkmann"s  ••  Lip-i\.;t. 


The  dressings  should  fit  suugly,  especially  about  the  edges,  and  should  not 
be  too  scanty. 

Three  days   after  the  operation    the  dressings  should   be  changed,  to 

permit  withdrawal  of  the  drain- 
age-tube. Five  or  six  days  more 
will  complete  the  essential  part 
of  the  cure. 

The  patient's  bowels  should 
be  moved  forty-eight  hours  after 
the  operation  by  a  large  enema  of 
soap-water.  Should  fever  set  in 
from  peritoneal  irritation,  a  saline 
purge  may  be  administered  with 
good  effect. 

As  long  as  the  patient  is  in 
bed,  nutrition  should  be  simple  and  moderate.  Xo  patient  should  be  per- 
mitted to  go  about  his  business  before  a  truss  can  be  worn  with  comfort. 
But  there  is  no  objection  to  his  being  up  and  about  the  room  with  a  well- 
fitting  ])ad  and  spica. 

Synopsis  of  successful  cases  hitherto  not  accounted  for  : 

Case  XVI. — Mrs.  C.  Reinhardt,  aged  fifty-four,  left  inguinal  incarcerated  hernia  of 
three  days'  duration.     Operation,  November  15,  1882.     Cured,  December  11th. 

Case  XVII. — Chas.  Koenscb,  four  months  old,  congenital  incarcerated  hernia.    Op- 
eration in  German  Dispensary.  January  26.  1883.     Cured,  February  22d. 

Case  XVIII.— G.  -John.     See  history,  page  24. 

Case  XIX. — Fred.  Hipp,  mechanic,   aged   sixty,  right   external  inguinal  hernia. 
Operation  at  German  Hospital,  April 
6,  1884.     Cured,  May  1st. 

Case  XX. — Mrs.  Emma  T.,  aged 
forty-seven,  left  femoral  hernia.  Op- 
eration, March  25,  1887.  Cured,  April 
10th. 

Case  XXI. — Anna  Brown,  aged 
fifty,  left  femoral  hernia.  Operation 
at  Mount  Sinai  Hospital  in  Septem- 
ber, 1880.  Discharged  cured,  end  of 
October. 

Case  XXII. — Martin  Thorwarth, 
cooper,  aged  sixty,  right  inguinal  her- 
nia. Operation,  February  12,  1880. 
Cured,  March  5th. 

Case  XXIII.— Adelaide   K.,   aged 
forty-five,    strangulated    left    femoral 
hernia.     Fecal  vomiting  of  a  week's  duration, 
viable.     Cured.  June  26,  1888. 

Case  XXIV.— Jacob  Feldstein,  errand-boy,  aged  fourteen,  strangulated  right  in 
guinal  hernia  Hay  10,  i559.— Operation  at  Mount  Sinai  Hospital.  Author's  modifi 
cation  of  Macewen's  suture.     Discharged  cured,  June  21,  1889. 


Fig.  109. — Manner  ritnp]ilyinu''  ilrer;sing  for  wounds 
of  scioto-iuiTuiual  rejrion. 


Herniotomy.     June  i7,  18R8. — Gut 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD. 


133 


I.  Eadical  Operation  for  Hernia. — In  performing  herniotomy  for  stran- 
gulation on  a  patient  whose  general  condition  is  good,  the  additional  steps 
for  radical  cure  may  be  at  once  carried  out  to  great 
advantage.     (Case  XXIV.) 

In  other  cases  of  non-strangu- 
lated hernia,    where  retention   by 


Fig.  110.— Herniotomy.     Patient  on  "  hip-rest,"  witli  completed  dresisiuj^.     Lateral  view. 

truss  of  a  very  large  scrotal  hernia  is  impracticable  on  account  of  wide 
distention  of  the  inguinal  canal,  or  where  adhesions  of  the  prolapsed  gut  or 
omentum  to  the  sac  render  reduction  impossible  and  make  attempts  at 
wearing  a  truss  a  torture  to  the  patient,  radical  operation  is  proper  and 
justified.  Due  observance 
of  the  rules  of  asepsis  makes 
this  operation  very  safe  as 
far  as  the  production  of 
purulent  peritonitis  is  con- 
cerned. Still,  some  danger 
of  septic  infection  can  nev- 
er be  excluded  with  posi- 
tive certainty.  Therefore, 
bloody  radical  operation 
should  be  discouraged  for  a 
hernia  that  can  be  retained 
by  a  properly  constructed 
truss. 

The  author  has,  in  his 
first  twelve  cases,  followed 
Czerny's  directions  in  per- 
forming radical  operation 
of  hernia,  the  several  steps 
of  which  are  as  follows  : 

After  due  preparation 
by  a  laxative,  preferably  castor-oil,  the  patient's  pubic  region  and  scrotum, 
especially  on  the  side  of  the  rupture,  are  shaved,  and  cleansed  the  day 
before  the  operation  with  brush,  soap,  and  hot  water,  and  are  wrapped  up 
in  a  clean  towel  dipped  in  a  three-per-cent  solution  of  carbolic  acid.  This 
wet  compress  is  again  covered  with  a  suitable  piece  of  oiled  silk  or  rubber 


Fig.  111.- 


-Completed  dressing  of  scroto-inguinal  region. 
Anterior  view. 


134  RULES  OF  ASEPTIC  AND  ANTISEPTIC   SURGERY. 

tissue,  and  fjistened  on  with  a  T-bandage.  On  the  day  of  the  operation 
the  patient  is  placed  on  the  table  and  anajsthetized,  a  full  and  good  anaes- 
thesia being  especially  desirable.  After  repeated  disinfection,  the  hernial 
sac  is  exposed  by  a  sufficiently  long  incision,  in  which  all  bleeding  vessels 
are  to  be  secured  by  ligature.  The  upper  angle  of  the  wound  should  be 
located  well  above  the  upper  margin  of  the  inguinal  ring  so  as  to  permit 
easy  manipulation. 

The  sac  is  incised,  and  its  edges  are  taken  up  by  a  number  of  artery 
forceps,  which  being  held  apart,  an  excellent  view  of  the  contents  of  the 
hernia  can  be  had.  Adhesions  of  the  omentum  to  the  sac  will  be  found  the 
most  common  cause  of  the  irreducibility,  the  gut  being  rarely  adherent. 
The  author  has  observed  only  one  case  of  old  hernia  in  which  adhesions  of 
the  gut  were  present  (case  Man).  The  favorite  place  of  omental  adhesions 
is  the  anterior  portion  of  the  neck  of  the  sac. 

As  soon  as  the  sac  is  open,  the  use  of  the  irrigator  has  to  be  discon- 
tinued, to  prevent  entrance  of  large  quantities  of  irrigating  fluid  into  the 
peritoneal  cavity.  The  lotions  used  for  rinsing  hands,  sponges,  and  instru- 
ments ought  to  be  very  mild  to  prevent  even  superficial  corrosion  of  the 
peritonasum.  The  author  has  generally  used  Thiersch's  boro-salicylic 
solution. 

A  suitable  sponge,  fastened  to  a  stout  piece  of  silk  or  catgut,  is  pushed 
well  up  into  the  inguinal  canal  to  prevent  the  entrance  of  blood  into  the 
abdomen.  Care  must  be  taken  not  to  select  a  too  brittle  sponge,  as  it  may 
happen  that,  on  removing  it,  some  portion  of  it  may  become  detached  and 
remain  in  the  belly. 

The  sac  must  be  split  open  to  within  a  quarter  of  an  inch  of  the  external 
inguinal  ring,  and  the  adherent  omentum  must  be  detached  from  the  sac 
by  preparation.  As  soon  as  the  distal  attachments  of  the  omentum  are 
severed,  it  is  withdrawn  a  little  farther  from  the  inguinal  canal,  and,  being 
deligated  in  small  portions  with  reliable  catgut,  it  is  cut  away  by  the  knife, 
or,  preferably,  the  therm o-cautery.  After  this  the  sac  is  wiped  out  clean, 
and,  the  sponge  being  withdrawn  from  the  inguinal  canal,  the  stump  of  the 
omentum  is  replaced  in  the  abdominal  cavity. 

In  dissecting  up  adherent  gut,  great  caution  must  be  observed  not  to  in- 
jure it.  Where  the  adhesions  are  very  close  and  extensive,  it  would  be 
better  to  excise  the  attached  portion  of  the  sac  with  the  gut,  and  replace 
them  together  in  the  peritongeum. 

Case  I. — Henry  Mau,  shoemaker,  aged  sixty-two.  Very  large  scrotal  hernia,  con- 
taining adherent  gut.  The  inguinal  ring  was  so  dilated  that  the  tips  of  three  lingers 
could  easily  be  slipped  within  the  abdominal  cavity.  February  S3,  1886. — Radical  op- 
eration at  the  German  Hospital.  Ether  anaesthesia  produced  violent  retching  and 
coughing,  so  that  the  irresistible  escape  of  gut  from  the  wound  rendered  operation 
impossible.  Chloroform  being  administered,  quiet  ana3sthesia  was  achieved.  The  ad- 
herent thick  gut  was  dissected  away,  togetlier  with  the  adhering  portions  of  the  sac, 
and  was  returned  to  the  abdominal  cavity.  The  remnant  of  the  sac  was  separated, 
closed  at  its  neck  with  a  purse-string  suture,  and  was  cut  away.  The  wide  gap  of  the 
inguinal  ring  was  closed  with  eight  sutures  of  stout  catgut,  and  the  external  wound 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.        I35 

was  drained  and  sewed  up.  Uninterrupted  recovery.  March  SSth.—The  patient  was 
discharged  cured,  with  instructions  to  wear  a  light  truss.  In  November,  1886,  he  pre- 
sented himself  with  a  relapse.  His  truss  had  been  broken,  and  he  neglected  to  have 
it  repaired.     In  a  lit  of  violent  coughing  the  rupture  reappeared. 

The  contents  of  the  sac  being  disposed  of,  excision  of  the  sac  is  the  next 
thing  to  be  done. 

In  most  cases  this  can  be  i^eadily  accomplished  by  stripping  up  the  sac 
from  the  surrounding  tissues  with  the  fingers,  the  scissors  being  only  occa- 
sionally needed  to  sever  resisting  bands,  which  generally  contain  vessels 
requiring  ligature.  In  some  instances,  however,  especially  in  cases  of  con- 
genital hernia,  the  separation  of  the  sac  is  not  easy.  The  sac  proper  is  not 
well  defined,  and  in  some  localities  consists  of  nothing  but  the  bare  peri- 
tonaeum. Hence  it  is  difficult  to  get  it  out  uninjured  and  in  one  piece. 
Another  difficulty  is  presented  by  the  close  relations  of  the  cord  and  its 
vessels  to  the  sac.  The  greatest  care  must  be  taken  to  properly  recognize 
them,  as  otherwise  they  may  be  accidentally  damaged. 

Case  II. — William  Litzebauer,  baker,  aged  twenty-seven.  Left  inguinal  irreducible 
hernia.  February  5,  1886. — Eadical  operation  at  the  German  Hospital.  Liberation 
of  adherent  omentum,  which  was  dehgated  and  cut  away.  In  dissecting  up  the  sac, 
the  vas  deferens  was  cut  across.  A  short  piece  of  stout  catgut  was  introduced  into  the 
patent  ends  of  its  lumen,  and  the  duct  was  united  by  four  fine  catgut  sutures  passed 
through  its  involucrum.  The  sac  being  removed,  the  external  ring  was  closed  by  six 
stout  catgut  sutures.  The  external  wound  was  drained  and  sewed.  February 
1th. — Purulent  urethral  discharge  was  noted ;  no  fever.  February  15th. — Change 
of  dressings.  "Wound  healed  by  adhesion,  left  testicle  somewhat  swollen  and  pain- 
ful. Tube  was  removed.  February  27th. — Urethral  discharge  disappeared,  testicle 
notably  decreased  in  size.  March  10th. — Discharged  cured,  with  slightly  enlarged 
testis. 

Congenital  irreducible  hernia  is  comparatively  frequent.  Four  of  the 
twelve  cases  operated  on  by  the  author  belonged  to  this  class.  One  was  com- 
plicated with  undescended  testicle. 

In  two  of  these  cases  castration  had  to  be  performed  along  with  the  radi- 
cal operation. 

Case  III. — August  B.,  painter,  aged  twenty-four.  August  S3,  1883. — Radical 
operation  at  the  German  Hospital.  The  omentum  was  found  adherent  to  the  left  testi- 
cle, and  contained  near  its  adhesion  to  this  organ  a  hard,  pigmented  tumor  of  the  size 
of  a  walnut.  The  sac  and  the  tunica  propria  of  the  testis  were  dotted  with  a  large 
number  of  pigmented  spots.  Therefore  the  omentum,  sac,  and  testicle  were  all  re- 
moved. Closure  of  inguinal  ring  by  catgut  sutures.  Treatment  of  external  wound 
as  usual.     September  20th. — Discharged  cured. 

Case  IV. — George  W.,  cattle-raiser,  aged  thirty-six.  Direct  inguinal  hernia  of 
left  side,  containing  the  undescended  testicle.  August  21^,,  1885. — Eadical  operation  at 
Mount  Sinai  Hospital.  The  attached  omentum  was  freed  and  removed.  The  atrophic 
testicle  was  also  taken  away.  Suture  as  usual.  September  Jfth. — Patient  strained  at 
stool,  whereupon  the  external  wound  reopened,  but  subsequently  healed  by  granu- 
lation.    October  2d. — Patient  was  discharged  cured. 

In  a  third  case  of  congenital  hernia,  in  an  infant,  eclamptic  attacks 


130  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

caused  repeated  protrusion  of  the  intestine,,  that  could  not  be  reduced  with- 
out the  employment  of  anaesthetics. 

Case  V.— Carl  Sclilichter,  eight  month?  old.  April  18,  i.<?Si5.— Prolapse  of  the 
gut  dnriug  a  convulsive  seizure.  Dr.  Meltzer,  tiie  family  attendant,  administered  chloro- 
form, whereupon  the  author  reduced  the  gut  with  some  difficulty.  The  accident  had 
occurred  the  fourth  time  in  spite  of  a  truss.  Radical  operation  was  at  once  performed. 
May  5th. — Patient  discharged  cured. 

Case  VI. — Franz  Faulhaber.  laborer,  aged  twenty-two.  Left  congenital  omental 
hernia.  J'tiy  28,  1885. — Radical  operation  at  the  German  Hospital.  Omentum  adher- 
ing to  sac  treated  as  usual.  Sac  was  cut  away  below  from  its  reflexion  upon  the  testi- 
cle, and  above  close  beneath  the  purse-string  suture.  Treatment  of  inguinal  ring  and 
external  wound  as  usual.  Uninterrupted  cure.  September  1st. — Patient  was  discharged 
cured. 

The  closure  of  the  sac  is  to  be  done  by  tlie  purse-string  suture,  depicted 
by  Fig.  106.  Rather  stout  catgut  must  be  used  for  this,  to  withstand  the 
powerful  tension  required  for  closing  the  circular  suture.  The  sac  is  cut 
away  below  the  knot,  and  any  bleeding  vessels  must  be  separately  de- 
ligated.  The  stump  is  pushed  well  up  within  the  internal  abdominal 
ring. 

In  applying  Czerny's  suture  of  the  inguinal  ring,  the  left  index-finger 
is  intruded  as  far  as  possible,  its  volar  aspect  being  directed  downward  and 
inward  to  protect  the  cord,  which  should  be  kept  near  the  inferior  and  inner 
angle  of  the  slit  of  the  inguinal  aperture.  A  strongly  curved  needle,  armed 
with  stout  catgut,  is  passed  first  through  the  conjoined  tendon,  then  through 
Poupart's  ligament,  all  stibcutaneously,  and  the  ends  of  the  thread  are  se- 
cured in  a  pair  of  artery  forceps  and  reflected  upon  the  abdomen,  where 
they  are  received  by  an  assistant.  This  first  suture  shoitid  be  placed  as  high 
tip  the  inguinal  ring  as  possible.  At  intervals  of  a  third  of  an  inch  from 
four  to  seven  stitches  are  applied  in  the  manner  indicated  :  then  they  are 
tied  firmly  by  surgeon's  knots  in  the  reverse  order.  A  small-sized  drainage- 
tube  is  placed  in  the  wound,  and  the  integument  is  united  by  finer  catgut 
sutures,  the  tube  being  brought  out  through  the  lower  angle  of  the  incision. 
An  antiseptic  dressing  is  next  applied  in  the  manner  shown  by  Figs.  108, 
109,  110,  and  111. 

The  first  change  of  dressings  should  be  made  on  the  third  day,  when 
the  tube  is  also  removed.  As  soon  as  the  wound  is  completely  closed,  the 
patient  is  permitted  to  get  up  with  a  spica  bandage  or  truss. 

The  patients  should  be  directed  to  continue  the  use  of  a  light  truss,  as 
this  is  the  only  reliable  security  against  recurrence. 

In  one  case  a  fibromatous  node  in  the  adherent  omentum  was  the  chief 
source  of  pain  complained  of  by  the  patient. 

Case  YII. — -Jacob  Christman.  laborer,  aged  thirty-nine.  August  15,  1885. — 
Radical  operation  at  the  German  Hospital.  A  hard,  irregular  node  was  occupying 
the  middle  of  the  prolapsed  and  adherent  omentum.  It  was  removed  with  the 
same.  Discharged  cured,  September  19th.  The  node  was  fibromatous  in  char- 
acter. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.        137 

In  another  case  a  subserous  fibro-lipoma  was  located  outside  of,  and  was 
■closely  connected  with,  the  neck  of  the  sac. 

Case  VIII. — Carl  Dille,  laborer,  aged  thirty.  Subserous  fibro-lipoma  and  left 
adherent  omental  hernia.  March  12^  i5S7.— Eadical  operation  at  the  German  Hos- 
pital. Removal  of  omentum  and  sac,  together  with  neoplasm.  Sutures  as  usual. 
April  9th. — Discharged  cured. 

The  remaining  four  cases  presented  nothing  unusual,  and  all  recovered 
without  mishap  : 

Case  IX. — Cliarles  Niemann,  locksmith,  aged  thirty.  Adherent  left  omental  hernia. 
February  19,  1887. — Radical  operation  at  the  German  Hospital.  March  12th. — Dis- 
charged cured. 

Case  X. — Martin  Hussmann,  baker,  aged  twenty-five.  Adherent  right  omental 
hernia.  March  3,  1887. — Radical  operation  at  the  German  Hospital.  April  7th. — 
Discharged  cured. 

Case  XI. — -Henry  Mehle,  barber,  aged  twenty-five.  Adherent  right  omental  hernia. 
January  8,  1886. — Radical  operation  at  tlie  German  Hospital.  February  ISth. — Dis- 
charged cured. 

Case  XII. — Mr.  M.  D.,  merchant,  aged  thirty-nine.  Very  massive,  growing,  adher- 
ent omental  hernia  of  the  right  side.  May  26,  1887. — Radical  operation  at  Mount  Sinai 
Hospital.     June  16th.— Fatieut  discharged  cured. 

Author's  Modification  of  Maceweii's  Operation. — To  test  its  value,  a 
modification  of  Macewen's  method  of  curing  hernia  was  employed  in  fifteen 
consecutive  instances.  Some  of  the  cases  were  very  grave,  either  on 
account  of  the  large  size  of  the  hernia,  or  because  of  the  presence  of  un- 
usual complications.  A  serious  mishap  occurred  only  once,  and  consisted  in 
the  sloughing  of  the  plug  formed  of  the  sac,  resulting  in  the  relapse  of  the 
disorder. 

The  initial  stejDS  of  this  procedure  are  identical  with  those  in  Czerny's 
method.  The  deviation  in  the  technique  commences  after  the  stripping  up 
of  the  sac  is  accomplished.  In  addition  to  the  detachment  of  the  sac 
proper,  the  parietal  peritoneum  is  also  detached  in  the  shape  of  a  halo  just 
inside  of  the  internal  abdominal  ring  for  the  distance  of  about  three  quarters 
of  an  inch,  forming  a  pocket  for  the  reception  of  the  plug  to  be  directly 
described.  The  sac  is  not  deligated  and  cut  off  as  in  Czerny's  procedure, 
but  a  stout  double  catgut  thread  is  stitched  to  its  distal  extremity,  and 
"passed  in  a  proximal  direction  several  times  through  the  sac,  so  that, 
when  pulled  upon,  the  sac  becomes  folded  upon  itself  like  a  curtain." 
After  this  the  double  thread  is  divided,  each  end  being  separately  threaded 
in  a  stout  curved  needle.  One  of  these  threads  is  passed  through  the 
abdominal  wall,  just  above  and  half  an  inch  to  the  inside  of  the  internal 
abdominal  ring,  while  the  other  is  carried  through  Poupart's  ligament 
below  and  to  the  outside  of  the  same  aperture.  None  of  the  stitches  should 
include  the  skin.  When  the  two  threads  are  pulled  upon,  they  will  first  fix 
the  plug  formed  by  the  sac  inside  of  the  abdominal  ring,  and  secondly,  by 
being  tied  in  a  knot,  will  very  effectually  approximate  the  edges  of  the 
inguinal  hiatus.     After  this  the  subsequent  stitches  are  passed  through  the 


138  RULES  OF  ASEPTIC   AND  ANTISEPTIC  SURGERY. 

conjoint  tendon  and  Poupart's  ligament  as  indicated  by  Macewen,  with  the 
difference,  however,  that  they  are  simple  interrupted  sutures,  and  less  com- 
plicated than  his  process.  When  all  the  stitches  are  in  situ,  they  are 
closed  one  after  the  other,  beginning  from  the  top.  No  drainage-tube  was 
employed  in  ten  cases  ;  in  three,  drainage  was  dispensed  with  after  the  first 
change  of  dressings  ;  in  two  cases  bland  suppuration  necessitated  the  use  of 
drainage-tubes  for  a  longer  period  of  time. 

Case  I. — Enormous  Irreducible  Inguinal  Hernia  of  five  years'  standing.  Anna 
Finkelstein,  aged  tbirty-four.  The  sac  reaching  down  to  the  knee-joint.  Operation 
January  24:,  1888,  at  Mount  Sinai  Hospital.  The  sac  contained  almost  all  the  in- 
testines and  the  left  ovary  and  tube.  Two  thirds  of  the  sac  were  removed  as  un- 
necessary. Macewen's  plug  being  formed  of  the  remnant.  Discharged  cured,  March 
12,  1888. 

Case  II. — Irreducille,  Very  Large  Inguinal  Hernia;  Bottom  of  Sac  containing 
Abscess  with  Fish-hone. — Lazar  Menasse,  tailor,  aged  forty -two.  Operation  November 
12, 1888,  at  Mount  Sinai  Hospital.  In  the  bottom  of  sac  an  abscess  containing  a  fish-bone 
was  opened,  the  intestine  forming  one  of  the  walls  of  the  abscess.  Disinfection  and 
replacement  of  gut.  In  dissecting  sac  the  vas  deferens  was  cut :  castration.  Dis- 
charged cured,  December  27,  1888.  ("  New  York  Medical  -Journal,"'  November  22, 
1888.) 

Case  III.— Very  Large  Xon-retainable  Inguinal  Hernia,  relapsed  after  Radical 
Operation  by  another  Surgeon. — Otto  Pahlmann,  waiter,  aged  forty.  Relapse  of 
hernia  nine  months  after  first  operation  (probably  Banks's).  Second  operation  at 
Mount  Sinai  Hospital,  January  16,  1890.  Castration  was  done  in  order  to  do  away 
with  cord.  Patient  contracted  severe  gastro-enteritis  two  weeks  after  the  operation, 
hence  his  discharge  was  delayed  till  March  22,  1890. 

Case  IV. —  Very  Large,  Xon-retainable  Inguinal  Hernia. — Operation  January  18, 
1889.     Discharged  cured,  February  17,  1889. 

Case  V. —  Very  Large,  Non-retainable  Inguinal  Hernia  of  Left  Side;  DouMe  En- 
cysted Hydrocele  of  Cord  on  Right  Side. — Operation  at  Mount  Sinai  Hospital,  Decem- 
ber 9,  1889.  Hydrocele  sacs  were  incised  and  drained  at  the  same  time.  Dis- 
charged cured,  February  1,  1890. 

Case  VI. — Large,  yon-retninable  Inguinal  Hernia. —  Franz  Wahl,  baker,  aged 
thirty-four.  Operation  February  21,  1889,  at  German  Hospital.  Discharged  cured, 
March  1,  1889. 

Case  VII. — Large,  Kon-retainable  Inguinal  Hernia. — Henry  Kattenhorn,  grocer, 
aged  twenty-six.  Operation  October  21,  1887,  at  German  Hospital.  Discharged 
cured,  November  17,  1887. 

Case  VIII. — IrreduciMe  Inguinal  Hernia. — Franz  Bosch,  tinsmith,  aged  twenty- 
three.  Operation  December  16,  1887,  at  Mount  Sinai  Hospital.  Adherent  omentum 
excised.     Discharged  cured,  December  31,  1887. 

Case  IX. — Irreducible  Inguinal  Hernia.— 'ilayer  Menaffe,  tailor,  aged  forty-two. 
Operation  August  27,  1887,  at  Mount  Sinai  Hospital.  Omentum  excised.  Discharged 
cured,  October  4,  1887. 

Case  X. — Irreducible  Inguinal  Hernia. — Herman  Neugroesche,  cigar-maker,  aged 
twenty-three.  Operation  March  18,  1889,  at  Mount  Sinai  Hospital.  Omentum  excised. 
Discharged  cured,  April  7,  1889. 

Case  XI. — Irreducible  Inguinal  Hernia. — Abraham  Blum,  peddler,  aged  seventeen. 
Operation  November  16,  1888,  at  Mount  Sinai  Hospital.  Omentum  excised.  Dis- 
charged cured,  December  27,  1888. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC   METHOD.        I39. 

Case  XII. — Irreducible  Inguinal  Hernia. — Gustave  Rinknitz,  laborer,  aged 
twenty-four.  Operation  October  13,  1888,  at  German  Hospital.  Omentum  excised. 
Discharged  cured.  November  5,  1888. 

Case  XIII. —  Umhilical.,  Irreducible  Hernia. — Annie  Smith,  housewife,  aged  forty- 
three.  Operation  May  14,  1888,  at  German  Hospital.  Omentum  excised,  sac  treated 
according  to  Macewen.  Umbilical  ring  pared,  then  sutured  with  six  silk-worm  gut 
button  sutures.     Discharged  cured,  June  17,  1888. 

Case  XIV. — Reducible  Inguinal  Hernia  of  Moderate  Size;  Sloughing  of  Sac; 
Relapse  of  Hernia. — Gustave  Sprenger,  waiter,  aged  thirty-one.  Operation  August  13, 
1888,  at  Mount  Sinai  Hospital.  Local  reaction  with  moderate  fever,  wound  reopened. 
Sloughed  sac  came  away  with  moderate  suppuration.  Discharged  cured,  September 
15,  1888.  Relapse  in  May,  1889.  Sloughing  probably  caused  by  too  tight  suturing. 
Had  the  patient  worn  a  truss,  relapse  would  have  been  prevented. 

Case  XV. — Reducible  Inguinal  Hernia  of  Recent  Origin;  Very  Slender  Sac ;  Re- 
lapse.^-V\i\\.  Meagher,  student,  aged  seventeen.  Operation  July  20,  1889.  Sac  was. 
found  to  be  very  thin  and  slender,  forming  a  rather  inadequate  plug.  Cured,  August 
15,  1899.     As  patient  wore  no  truss,  relapse  was  noticed  in  April,  1890. 

To  secure  the  patient  against  the  clanger  of  a  relapse,  the  wearing  of  a 
truss  seems  to  be  very  advisable. 

It  has  been  urged,  notably  by  McBurney,  Weir,  and  Abbe,  of  New  York, 
that,  after  radical  operation,  healing  of  the  external  wound  by  granulation 
is  preferable  to  primary  union,  on  account  of  the  larger  mass  of  cicatricial 
matter  resulting  from  the  granulating  process.  To  the  author  this  advan- 
tage seems  of  doubtful,  certainly  of  only  passing,  value,  as  the  massive 
cicatrix,  first  hard  and  resisting,  must  in  the  course  of  time  become  atro- 
phied, soft,  and  yielding,  and  will  not  be  able  to  withstand  for  a  long  time 
the  constant  impact  of  the  intra-abdominal  pressure.  The  analogy  of  this 
fact  with  the  experiences  gathered  about  the  wounds  resulting  from  lapa- 
rotomy can  not  be  gainsaid.  These,  when  the  healing  of  the  abdominal 
incision  was  not  by  primary  union,  and  the  cicatrix  produced  by  a  long 
process  of  granulation  is  very  wide  and  massive,  regularly  terminate  in 
ventral  hernia. 

3.   Laparotomy. 

a.  Exploratory  Incision. — Although  the  aseptic  method  has  very  mate- 
rially reduced  the  dangers  of  exploratory  laparotomy,  its  wanton  and  un- 
necessary practice  must  be  deprecated  on  several  grounds.  First  of  all, 
no  surgeon  is  absolutely  secure  in  his  practice  against  accidental  and  un- 
expected, often  unexplained,  wound  infection.  Secondly,  the  dangers  of 
ansesthesia,  and  of  conditions  indirectly  caused  by  it,  as  nephritis,  pneu- 
monia, thrombosis,  and  embolism,  are  ever  present,  and  usually  surprise 
the  surgeon  when  least  expected. 

Exploratory  incision  is  only  justified  where,  in  the  presence  of  a  disorder 

threatening  life,  all  known  means  for  establishing  a  diagnosis  have  been 

exhausted  without  positive  result,  or  where  the  extent  and  exact  relations. 

of  a  mechanical  disturbance  can  not  be  estimated  without  ocular  inspection, 

and  digital  examination. 
20 


140  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

Due  observance  of  the  rules  against  infection  will  exclude  suppurative 
peritonitis  with  great  certainty.  The  detail  of  the  procedure  is  treated  in 
the  chapter  on  abdominal  tumors. 

Case  T. — Frc<l.  Kahn,  aged  eleven.  Intestinal  ohstruction  of  seven  days'  duration. 
Fecal  vomiting,  very  great  tyra})anites,  and  threatening  exhaustion.  No  fever.  June 
27,  1882. — Laparotomy  under  ether.  In  the  right  iliac  fossa  an  immovable  convolu- 
tion of  small  gut  could  be  felt.  The  incision  was  sutficiently  extended  to  enable  the 
author  to  inspect  the  locality.  It  was  found  that  the  tip  of  the  vermiform  appendix 
was  attached  to  the  parietal  peritonaeum.  A  large  loop  of  the  ileum  had  slipped  through 
the  hiatus  thus  formed,  and  was  there  incarcerated.  The  vermiform  appendix  was  cut 
between  two  ligatures,  and  the  loop  of  intestine  became  free.  Reduction  of  the  enor- 
mously distended  intestines  was  impossible.  At  tiie  suggestion  of  Dr.  A.  Seibert,  an 
enema  was  administered,  and  it  brought  away  a  large  quantity  of  gas,  whereupon  the 
somewhat  collapsed  gut  could  be  replaced,  and  the  abdominal  incision  closed.  The 
operation  lasted  thirty  minutes.  Deep  collapse  followed,  in  which  the  patient  died 
twelve  hours  after  the  operation. 

Very  likely  an  early  operation  would  have  been  followed  by  a  better 
result. 

Case  II. — Mary  Block,  aged  twenty-seven.  Symptoms  of  subacute  intestinal  ob- 
struction, with  fever  and  vomiting  of  all  iugesta.  Moilerate  distention  of  abdomen. 
Tumor  in  right  loin,  which  is  painless  on  pressure.  Trouble  of  a  week's  standing. 
January  8,  1889. — Laparotomy  reveals  a  convolution  of  much  reddened,  distended,  and 
oedematous  gut  in  the  right  iliac  fossa,  surrounded  by  pale  and  normal-looking  empty 
intestine.  The  hypergemic  portion  of  gut  proved  to  consist  of  about  two  feet  of  the 
lowest  part  of  the  ileum,  twisted  on  its  mesentery,  the  vessels  of  which  showed  marked 
venous  stagnation.  The  twisted  coils  of  gut  were  easily  restored  to  their  normal  posi- 
tion, as  no  adhesions  had  as  yet  formed.  The  tumor  in  the  right  loin  was  found  to  be 
a  somewhat  enlarged  movable  kidney.  Closure  of  wound.  Uninterrupted  recovery. 
Patient  discharged  cured,  February  26th. 

Case  III. — Philippine  Pahler,  aged  thirty-five.  Pyloric  cancer  of  stomach.  Febru- 
ary 18,  1886. — Probatory  abdominal  incision  at  the  German  Hospital,  with  a  view  to 
possible  resection  of  the  j)ylorus.  The  extension  of  the  disease  to  the  retro-peritoneal 
glands,  the  pancreas,  and  omentum  put  the  contemplated  step  out  of  question,  where- 
fore the  incision  was  closed.  March  11th. — Patient  discharged  with  firmly  healed 
wound. 

Case  IV. — Albert  Schroeder,  painter,  aged  thirty.  Large  retro-peritoneal  tumor 
located  behind  hepatic  flexure  of  colon,  causing  intestinal  stenosis.  August  8,  1882. — 
Probatory  incision  at  the  German  Hospital  established  the  fact  of  the  inoperability  of 
the  swelling — a  sarcoma  of  the  mesocolic  glands.  Closure  of  wound.  Atigust  9th. — 
Patient  died  in  collapse. 

h.  Abdominal  Tumors : 

(a)  General  Eemarks.— To  avoid  infection  from  without,  it  is  first 
necessary  to  carefully  shave  the  belly  and  pubic  region  of  the  patient,  then 
to  scrub  it  well  with  soap  and  brush,  and  finally  to  rub  it  off  with  a  1 : 1,000 
solution  of  corrosive  sublimate.  The  navel  ought  to  be  very  thoroughly 
cleansed  of  deposits  of  dirt.  The  scrupulous  cleansing  and  disinfection  of 
hands,  instruments,  sponges,  and  other  utensils  should  render  unnecessary 


SPECIAL  APPLICATION   OF  THE  ASEPTIC   METHOD.        141 


Fig.  112. — Ascites  and  ovarian  tumor.  Patient 
ready  for  operation  in  the  lateral  posture. 
Case  of  Dr.  W.  L.  Estes,  of  Bethlehem,  Pa. 


the  application  to  the  peritoneal  cavity  of  disinfectant  lotions,  which,  by 
their  corrosive  properties,  may  produce  mischief. 

The  usual  measures  adopted  for  protecting  the  body  of  the  patient  against 
wetting  and  undue  cooling  off,  as  the  wrapping  up  of  the  extremities  in 

flannels,  and  the  spreading  of  rubber  cloths  over 
the  trunk  and  lower  limbs,  leaving  exposed  noth- 
ing but  the  abdomen,  demand  special  care  and 
attention.     Excessive  loss  of  hody  Jieat  is  a  great 

factor  in  determining 
collapse,  and  sliould  he 
guarded  against  most 
sedulously. 

The  principle  of  no7i- 
exposure  applies  equally 
to  the  contents  of  the 
abdominal  cavity.    The 
greater  the  incision,  the 
more  attention  must  be  paid  to  the 
non-exposure  of  the  intestines.  Hot, 
f.at  sponges  or  tozoels  should  hide 
from    view    everything   except    the 
very  spot  subjected  to  surgical  ma- 
nipulation. 

The  use  of  the  spray  apparatus  during  abdominal  operations  is  harmless, 
but  unnecessary.  Certainly  it  forms  a  very  objectionable  feature  of  the 
original  Listerian  method, 
and  has  been  abandoned 
in  general  as  well  as  ab- 
dominal surgery  by  most 
operators.  The  author  has 
not  used  the  spray  appa- 
ratus since  1881. 

The  control  of  hcemor- 
rhage  is  of  the  utmost 
importance  to  the  success 
of  abdominal  operations. 
This  and  the  former  re- 
quirements can  be  best 
fulfilled  by  an  intelligent 
observance  of  the  rules  laid 
down  in  the  paragraphs  on 
the  technique  of  surgical 
dissection  and  the  removal 
of  tumors.    The  principles 

there  explained  remain  unchanged,  their  application  to  abdominal  tumors 
only  being  somewhat  modified  by  the  peculiarities  of  the  locality. 


Fig.  113. 


-Protection  of  the  intestines  by  flat  sponges 
arranged  ahout  the  tumor. 


142 


RULES  OF   ASEPTIC   AND   ANTISEPTIC  SURGERY. 


An  ample  incision  is  the  first  condition  of  the  safe  removal  of  an  abdomi- 
nal tumor.  When  a  unilocular,  non-adherent  C3-st  is  to  be  exsected,  a  small 
incision  will  be  ample,  because  the  cyst,  however  large,  can  be  emptied  by 
tapping,  and  is  thus  reduced  to  the  elongated  proportions  of  a  flat  band, 
which  can  be  extracted  through  the  small  incision  without  much  force  until 
the  pedicle  comes  in  view. 

Multilocular  cysts  that  can  not  be  emptied  readily,  or  solid  tumors,  or 
growths  with  many  adhesions,  must  be  freely  exposed,  to  enable  the  sur- 


FiG.  114.— Protection  of  the  intestines  in  ovariotomy  by  hot  towels. 

geon  to  see  what  is  to  be  done.  Accidental  laceration  of  the  gut,  bladder, 
or  large  veins  will  not  easily  occur  while  the  adhesions  binding  the  tumor 
to  these  organs  are  exposed  to  view. 

Disregard  of  this  plain  and  rational  rule  is  the  cause  of  many  an  accident 
and  mishap  that  might  be  easily  avoided  otherwise. 

Note. — However  important  the  incision  and  final  suture  of  the  abdominal  walls  may  be,  it 
must  not  be  forgotten  that  tliey  do  not  represent  the  critical  part  of  most  abdominal  operations. 
The  abdominal  incision,  being  a  preliminary  measure,  should  not  occupy  too  much  time.  Of 
course,  it  must  be  done  lege  ar/is.  but  with  expedition.  Bleeding  vessels  need  not  be  tied  here, 
as  the  pressure  of  the  hemostatic  forceps,  exerted  for  ten  or  fifteen  minutes,  will  effectually 
arrest  hsemorrhage.  Here,  as  elsewhere,  cutting  between  two  forceps  will  be  more  expeditious 
and  safer,  than  the  use  of  the  grooved  director. 

The  skillful  and  unstinted  use  of  mass  ligatures  by  means  of  Thiersch's 
spindle  apparatus  will  render  the  dissection  even  of  extensively  adherent 
abdominal  tumors  remarkably  bloodless  and  safe.  Strong  catgut  is  prefer- 
able to  silk,  as  the  latter  is  known  to  have  been  the  cause  of  suppuration  in 
a  good  many  cases,  although  the  silk  was  prepared  in  a  seemingly  proper 
fashion.  Extensive  masses  of  tissue,  especially  if  their  shape  approaches 
that  of  a  membrane,  should  not  be  included  in  a  single  ligature,  as  they  are 
very  apt  to  slip  at  the  edges.  It  is  safer  to  divide  them  into  a  number  of 
smaller  portions  which  should  be  separately  tied.  This  rule  applies  to  the 
omentum  especially. 


SPECIAL  APPLICATION   OF   THE   ASEPTIC   METHOD.         I43 

Adhesions  or  pedicles  of  a  more  cylindrical  shape  can  be  safely  tied  in 
one  mass  without  risking  the  slipping  of  the  ligature.  Every  mass  should 
be  included  in  two  ligatures,  between  which  it  can  be  severed  with  the  knife 
or,  better,  the  thermo-cautery. 

Transfixion  of  pedicles  with  a  sharp  Peaslee's  needle  is  not  advisable,  as 
large  veins  passing  into  the  mass  may  thus  be  cut  open  and  cause  trouble- 
some haemorrhage  from  a  point  not  included  in  the  ligature.  It  is  better  to 
use  a  blunt  instrument,  such  as  Thiersch's  spindle,  or  a  dressing  or  artery  for- 
ceps, which  will  pass  through  any  pedicle  easily  without  injuring  the  vessels. 

Where  the  adhesion  or  pedicle  is  too  short,  and  the  tumor  too  large,  to 
admit  of  easy  manipulation  under  the  guidance  of  the  eye,  the  use  of  a 
temporary  elastic  ligature,  with  or  without  preliminary  transfixion  to  pre- 
vent slipping,  will  be  found  a  welcome  expedient.  To  this,  a  rather  stout, 
solid  band  of  [not  rotten)  pure  gum-elastic,  and  one  or  more  round  probe- 
pointed  steel  needles  are  necessary.  The  pedicle  is  first  transfixed  singly 
or  crucially,  then  the  rubber  band  is  thrown  around  the  needles  beyond  the 
place  of  transfixion.  The  ends  of  the  tightened  rubber  are  crossed  and 
secured  at  the  crossing  by  a  stout  pedicle-clamp.  After  this  the  tumor  can 
be  cut  away,  and  the  pedicle,  becoming  more  accessible,  can  be  divided  and 
tied  off  with  catgut  in  several  jiortions.  As  soon  as  this  is  done  the  clamp 
is  loosened,  the  rubber  is  removed,  and  the  tied-off  masses  are  trimmed  and 
seared  with  the  actual  cautery. 

Close  adhesions  of  the  gut  require  special  care.  Recent  adhesions  are 
easily  separated  by  blunt  preparation,  but  cause  a  good  deal  of  oozing. 
Much  wiping  and  sponging  of  the  oozing  points  is  apt  to  prolong  haemor- 
rhage, for  reasons  exjjlained  elsewhere.  It  is  better  to  cover  these  points 
with  a  flat  sponge,  and  to  let  them  alone  till  haemorrhage  ceases  spontane- 
ously. The  blood  that  found  its  way  into  the  abdomen  must  be  sponged 
out  at  the  final  toilet.  Old  adhesions  of  the  intesti7ie  are  very  dense,  and 
efforts  at  their  blunt  separation  may  easily  lead  to  injury  of  the  gut.  Dis- 
section by  the  scaljDcl,  the  line  of  section  being  well  away  from  the  intes- 
tine, will  be  found  the  most  expeditious  mode  of  proceeding.  Spurting 
vessels  must  be  tied,  and  as  soon  as  the  adhesion  becomes  less  close  and 
the  formation  of  masses  by  blunt  separation  possible,  mass  ligatures  should 
be  applied. 

Forcible  blunt  preparation  in  the  vicinity  of  large  veins,  more  especially 
of  the  large  plexus  regularly  encountered  in  the  bottom  of  the  small  pelvis 
near  the  uterus  and  its  adnexa,  is  hazardous,  on  account  of  the  haemorrhage 
often  caused  by  laceration  of  the  delicate  walls  of  these  vessels.  Careful 
isolation  and  double  deligation,  with  subsequent  cutting  between  the  liga- 
tures, are  the  best  safeguard  against  dangerous  haemorrhage. 

Blunt  dissection,  preferably  by  the  tips  of  the  fingers,  is,  however,  emi- 
nently proper  where  the  peritoneum  is  to  be  stripped  up  from  underlying 
tissues.  It  is,  in  fact,  the  only  safe  way  of  separating  tumors  that  are 
located  between  the  folds  of  the  broad  ligament,  in  the  mesentery,  or  in 
any  portion  of  the  retro-peritoneal  space. 


144  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

Exploratory  puncture  and  aspiration  of  exposed  abdominal  cysts  of  un- 
known contents  with  a  fine,  hollow  needle  is  very  advisable,  as  the  exact 
knowledge  of  the  nature  of  the  cystic  contents  may  materially  modify  sub- 
sequent steps  of  the  operation. 

If  the  cystic  fluid  be  bland,  its  esca{)e  into  the  peritoneal  cavity  does  not 
signify  much,  provided  that  careful  cleansing  be  employed  before  the  clos- 
ure of  the  wound.  But  when  the  cyst  contains  purulent  or  fetid  serum, 
accidental  soiling  of  the  peritonaeum  by  it  may  effectually  destroy  all  chances 
of  recovery. 

Whenever  puncture  of  an  exposed  tumor  is  determined  on,  whether  by 
a  small  or  large-sized  instrument,  good  care  must  be  taken  to  prevent,  dur- 
ing and  after  the  act,  the  escape  of  cystic  fluid  through  the  puncture-hole 
into  the  abdominal  cavity.  To  do  this  it  is  necessary  to  surround  the 
needle  or  trocar  with  a  number  of  flat  sponges  laid  on  the  tumor.  As  soon 
as  the  piston  is  withdrawn  the  nature  of  the  fluids  appearing  in  the  barrel 
of  the  syringe  will  become  manifest.  If  it  be  clear  and  limpid,  no  further 
precaution  need  be  taken.  Should  the  fluid  appear  to  be  turbid,  or  mani- 
festly purulent,  the  barrel  should  be  emptied  and  refilled  and  emptied  again, 
until  the  tension  of  the  sac  becomes  so  far  reduced,  that  its  transfixed  portion 
may  be  raised  in  a  fold  and  secured  by  a  large  clamp.  The  sponges  used 
for  this  step  of  the  operation  should  be  at  once  discarded. 

To  prevent  laceration  of  the  sac  or  capsule,  the  utmost  gentleness  and 
care  should  be  practiced  in  handling  the  tumor.  The  use  of  sharp  re- 
tractors and  vulsellum  forceps,  or  forcible  traction  with  or  without  blunt 
force  of  any  kind,  are  extremely  ill-advised.  Not  only  may  the  sac  be 
torn,  but  large  veins  spread  out  over  the  surface  of  the  tumor  may  be  in- 
jured, and  give  rise  to  uncontrollable  haemorrhage.  The  aperture  of  a  torn 
vein  can  not  be  easily  occluded  by  any  kinds  of  artery-clamp,  first,  because 
of  its  irregular  shape  and  extension,  and  principally  because  the  tension  of 
the  capsule  of  a  solid  tumor  precludes  the  formation  of  a  fold  that  could  be 
conveniently  grasped. 

Note. — The  author  recalls  an  instance  witnessed  by  him  where,  during  the  removal  of  a 
large  uterine  growth  through  an  inadequate  incision,  sharp  retractors  were  used  in  forcibly 
developing  the  mass  from  the  abdominal  cavity.  Several  large  veins  being  torn,  profuse  haem- 
orrhage set  in.  The  incision  was  somewhat,  but  still  insufficiently,  enlarged,  and,  more  force 
being  applied,  the  tumor  was  finally  brought  out  of  the  abdomen.  But  very  soon  it  became  evi- 
dent that,  in  consequence  of  the  forcible  manipulation,  the  transverse  colon,  which  was  closely 
adherent  to  the  posterior  aspect  of  the  tumor,  had  been  extensively  torn.  Enterorrhaphy  did  not 
save  the  patient's  life,  which  was  forfeited  by  the  injudicious  management  induced  by  super- 
stitious fear  of  a  "  large  "  abdominal  incision. 

The  tenet  of  making  small  incisions  for  the  removal  of  abdominal  tumors 
had  its  origin  in  the  justified  disinclination  to  expose  a  large  peritoneal  sur- 
face to  the  contaminating  and  refrigerating  effect  of  the  atmospheric  air. 
And  unnecessarily  long  incisions  are  certainly  to  be  avoided.  But  the  sur- 
geon's discretion  must  decide  the  question  of  the  size  of  the  incision,  the 
principle  of  safe  dissection  under  the  guidance  of  the  eye  being  herein  of 
the  first  importance. 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.         145 

Undue  cooling  off  of  the  peritonseum  is  a  very  undesirable  thing,  on 
account  of  the  collapse  it  may  induce  ;  therefore,  all  portions  of  the  abdomi- 
nal organs  that  are  not  actually  under  dissection  should  be  carefully  covered 
up  by  large  flat  sponges  or  clean  towels  wrung  out  of  hot  Thiersch's  solution. 

Note. — To  always  have  a  sufficient  supply  of  warm  sponges  and  towels,  the  following 
arrangement  will  be  found  convenient :  A  tin  pan  or  basin,  containing  the  sponges  or  towels 
immersed  in  Thiersch's  solution,  is  rested  on  the  tops  of  two  clean  bricks  stood  on  edge.  A 
blazing  alcohol-lamp  is  placed  between  the  bricks  and  underneath  the  vessel,  which,  being  cov- 
ered with  another  pan,  will  preserve  unchanged  the  temperature  of  its  contents.  For  larger 
operations,  three  or  four  similarly  prepared  pans  can  be  conveniently  arranged  on  a  separate 
table. 

Whenever  a  stout  adhesion  or  a  pedicle  is  deligated  and  cut  through, 
it  should  be  dropped  back  into  its  natural  position,  where  it  should  be 
inspected  for  a  short  while  to  see  whether  haemorrhage  is  thoroughly  con- 
trolled by  the  ligature.  Oozing  points  should  be  touched  with  the  thermo- 
cautery, but  care  must  be  taken  not  to  go  too  near  the  ligature,  for  fear  of 
burning  it. 

Oozing  points  located  on  the  gut  should  never  be  touched  with  the 
thermo-cautery. 

It  is  best  not  to  tap  at  all  dermoid  cysts  or  tumors  containing  clearly 
septic  fluid,  as  the  integrity  of  the  cyst-wall  is  the  only  guarantee  of  pre- 
venting contamination  of  the  abdominal  cavity  by  cystic  fluids.  Eather 
increase  the  external  incision,  and  remove  the  tumor  intact. 

The  relations  of  the  bladder  to  the  tumor  should  be  carefully  considered. 
Greig  Smith  advises  not  to  empty  the  bladder  before  operation,  and  it  is 
undeniable  that  a  full  bladder  can  not  be  well  overlooked  or  injured.  In- 
Jury  to  an  empty  and  collapsed  bladder,  on  the  other  hand,  has  repeatedly 
occurred  in  the  presence  of  abnormal  adhesions  of  the  organ  to  the  tumor. 
To  further  ascertain  the  extent  of  adhesions  of  the  bladder,  the  introduc- 
tion and  manipulation  of  a  solid  male  urethral  sound  will  be  found  very 
useful. 

Note. — Catheterism  should  be  done,  if  possible,  by  a  person  not  employed  about  the 
wound,  or,  if  this  be  not  feasible,  careful  cleansing  and  disinfection  of  the  hands  should  follow  it. 

After  the  removal  of  the  tumor,  the  toilet  or  cleansing  of  the  abdominal 
cavity  has  to  be  attended  to.  Sponges  attached  to  long  handles  are  very 
convenient  for  this  purpose.  With  them  first  the  lumbar,  then  the  vesico- 
uterine recesses,  finally  the  utero-rectal  or  Douglas's  pouch,  are  to  be  thor- 
oughly cleansed  and  dried. 

In  the  presence  of  large  denuded  surfaces  lacking  peritoneal  investment, 
a  glass  or  hard-rubber  drainage-tube  is  to  be  inserted  into  the  bottom  of 
the  small  pelvis.  It  can  be  brought  out  through  a  counter-opening  made 
into  the  vagina  from  Douglas's  pouch,  or  through  the  lower  angle  of  the 
abdominal  incision. 

In  the  former  case,  the  external  end  of  the  tube  projecting  into  the 
vagina  or  in  the  vulva  must  be  wrapped  in  a  packing  of  iodoformized 
gauze,  which  ought  to  be  changed  whenever  it  gets  saturated.     When  the 


146 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


tube  is  brought  out  through  tlic  abdominal  incision,  its  outer  end  must 
be  so  dressed  as  to  be  easily  accessible.  Every  liour  the  serum  collecting 
in  its  bottom  should  be  exhausted  with  a  pad  of  absorbent  borated  cotton 
fixed  to  a  handle,  or  with  a  long-nozzled  syringe.  In  the  intervals  the  tube 
should  be  loosely  filled  with  a  strip  of  iodoform  gauze.  As  the  serum  dimin- 
ishes, this  process  is  gone  through  Avith  at  longer  intervals.  As  soon  as  tlio 
tube  remains  dry  for  several  hours,  generally  about  the  third  day,  it  can  be 
withdrawn. 

Note. — Miculicz  has  successfully  substituted  for  tlic  drainage-tube  a  loose  packing  and  fillet  of 
iodoformized  gauze,  brought  out  through  an  angle  of  the  wound.  The  exsiccation  of  the  secre- 
tions by  this  arrangement  is  certainly  very  effective.  The  fillet  should  be  removed  on  the  third 
or  fourth  day. 

The  closure  of  the  abdominal  wound  should  he  done  as  rapidly  as  thor- 
oughness will  permit,  simplicity  and  solidity  of  the  suture  being  the  main 
desiderata. 

A  Peaslee's  needle  is  thrust  on  one  side  through  the  entire  thickness  of 
the  abdominal  wall,  including  the  peritonaeum,  and  is  brought  out  in  a 
similar  manner  on  the  other.  The  points  of  entrance  and  emergence  should 
be  at  least  two  inches  from  the  edges  of  the  wound.  A  piece  of  well-disin- 
fected silver  wire  or  stout  silk-worm  gut,  armed  with  a  quill,  or  a  leaden 
button  and  shot,  is  threaded  through  the  eye  of  the  needle.  This  is  then 
withdrawn,   bringing  out  the  end   of   the   thread   from   one   side   of   the 


1  .-uture  of  abdominal  incision. 


wound  to  the  other,  where  it  is  temporarily  secured  by  an  artery  forceps. 
Three,  four,  or  more  retentive  sutures  of  this  kind  are  passed  at  intervals  of 
about  an  inch,  until  the  entire  length  of  the  wound  is  covered  by  them. 

Note. — While  the  stitches  are  being  passed,  a  flat  sponge  should  be  kept  spread  over  the 
intestines  to  receive  the  blood  escaping  from  the  stitch-holes. 

If  the  patient's  condition  be  good,  the  peritonaeum  may  be  separately  united  by  a  row  of 
catgut  sutures  placed  between  the  silver  or  silk-worm  gut  stitches.     But  this  is  not  essential. 


SPECIAL  APPLICATION   OP  THE  ASEPTIC  METHOD. 


147 


I'iG.  116. — Completed  plate  and  shot  suture  of  abdominal  wounds. 


After  the  withdrawal  of  the  flat  sponge,  and  a  final  cleansing  of  the  peri- 
touseum  by  sponges  fixed  to  long  handles,  a  quill  is  applied  to  the  unarmed 

end  of  the  thread,  and 

'  is  tightened  until  the 

edges  of  the  incision 
are  raised  in  the  shape 
of  a  low  ridge.  Or, 
if  leadbuttonsare  tobe 
used,  one  of  these  is 
slipped  on  the  thread 
with  a  perforated  shot, 
the  thread  is  tight- 
ened, and  the  shot  is 
pinched.  After  this, 
a  sufficient  number  of 
exact  "  sutures  of  co- 
aptation," made  of  fine 
catgut,  secure  the  edges 
of  the  incision.  (Figs. 
115  and  116). 

The  dressings  con- 
sist of  a  few  strips  of  iodoform-gauze,  and  an  ample  compress  of  sublimated 
gauze  over  it,  all  snugly  fastened  by  several  strips  of  adhesive  plaster  and  a 
broad  flannel  or  gauze  bandage. 

On  from  the  eighth  to  the  tenth  day  the  dressings  are  changed,  and  the 
retentive  sutures  are  removed ;  but  the  bandage  must  be  worn  for  some 
time  to  serve  as  a  support  to  the  fresh  cicatrix. 
(b)  Special  Obseevations  : 

a.  Ovarian  Tumors.  —  Probatory  puncture  of  an  abdominal  tumor 
through  the  walls  of  the  belly  is  not  an  indifferent  matter.  .  If  the  tumor 
be  cystic,  and  its  wall  very  tense,  escape  of  a  limited  quantity  of  cystic 
contents  is  unavoidable.  Bland  and  very  thin  contents  may  escape  iu 
large  quantities  without  causing  irritation.  A  large  number  of  cases  are 
on  record  in  which  probatory  puncture  of  cysts  of  the  broad  ligament  was 
followed  by  cure. 

Case. — Mrs.  Francisca  N.,  liquor-dealer's  wife,  aged  tliirty-four,  was  tapped, 
August  31,  1877,  for  a  large  abdominal  cyst.  About  a  gallon  of  fluid,  characteristic 
of  a  cyst  of  the  broad  ligament,  was  removed,  but  a  considerable  quantity  was  left 
behind.  In  a  short  time  the  flabby,  fluctuating  swelling  disappeared  entirely,  and  the 
woman  remained  free  from  any  further  trouble. 

Escape  of  minute  portions  of  purulent  cyst-fluid  is  apt  to  cause  circum- 
scribed peritonitis,  resulting  in  more  or  less  extensive  adhesions.  Larger 
quantities  of  septic  matter,  that  find  their  way  into  the  peritoneal  cavity, 
may  produce  fatal  j)urulent  peritonitis. 

The  preparations,  with  a  view  to  the  aseptic  performance  of  exploratory 
21 


148  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

or  evacuating  pimcture,  must  be  very  thorough,  as  the  use  of  an  unclean 
needle  or  trocar  may  be  the  source  of  peritonitis  or  suppuration  of  the  sac. 
The  hollow  needle  or  trocar  to  be  used  m.ust  be  sterilized  either  by  boiling 
for  an  hour,  or  by  incandescence  in  the  alcohol  flame. 

When  an  exposed  cyst  is  to  be  tapped  or  emptied  by  incision,  the  patient 
should  be  turned  over  on  her  side.  An  assistant  should  prevent  the  escape 
of  gut ;  another  one  should  surround  the  place  of  tajiping  with  a  circle  of 
sponges  to  receive  fluid  that  may  escape  alongside  of  the  instrument.  Tait's 
trocar  is,  on  account  of  its  simplicity,  the  best  one  of  all  instruments  devised 
for  evacuating  cysts. 

As  soon  as  the  cyst  begins  to  collapse,  its  folds  should  be  taken  up  with 
large  clamps.  The  empty  cyst  is  then  withdrawn  to  the  pedicle,  which  is 
tied  in  one  or  more  portions  and  cut  off. 

Case  I. — Mrs.  Dorothy  Grunewald,  aged  sixty-one,  multipara.  Unilocular  cyst  of 
tlie  left  ovary.  December  19,  1882. — Ovariotomy.  External  incision  four  inches  long. 
Cyst  presenting,  patient  was  brought  in  lateral  position.  Tapping,  evacuation,  and 
extraction.  Rather  stout  pedicle  transfixed  with  thumb- forceps,  and  tied  in  four  por- 
tions, then  cut  otf  and  dropped  back  into  the  abdomen.  Uninterrupted  recovery. 
January  If,,  1883. — Discharged  cured. 

Multilocular  cysts  can  be  best  emptied  by  making  a  free  incision  through 
their  presenting  part,  through  which  the  hand  can  be  carried  within  the 
tumor  to  break  up  intervening  septa.  All  this  should  be  done  extra-abdom- 
inally  if  possible. 

When  a  cyst  is  found  extensively  adherent,  its  contents  should  be  care- 
fully mopped  out  with  a  sponge,  and  the  interior  of  the  sac  should,  be  dis- 
infected while  the  patient  is  in  the  lateral  posture.  After  this  a  large  sponge 
is  thrust  into  and  left  within  the  cavity  until  the  cyst  is  dissected  out. 

Case  II. — Miss  Lucretia  Bernard,  aged  seventy-two,  virgin.  Very  large  multilocu- 
lar ovarian  cyst  of  the  right  side,  causing  intense  dyspnoea.  August  8,  1881. — Punct- 
ure and  partial  evacuation  at  Mount  Sinai  Hospital,  resulting  in  marked  relief  of  the 
dyspnoea.  August  10th. — Fever  set  in,  with  some  abdominal  tenderness,  and  suppura- 
tion of  the  cyst  was  apprehended.  August  13th. — Ovariotomy.  Incision  twelve  inches 
long.  Broad,  recent  adhesion  of  the  sac  to  the  anterior  abdominal  wall  severed  by 
blunt  preparation.  Patient  being  brought  into  the  side  position,  the  cyst  was  first 
tapped,  then  incised,  and  its  volume  was  much  reduced  by  breaking  down  septa  by  the 
hand.  Some  haemorrhage  occurring,  a  large  sponge  was  thrust  into  the  sac,  and  the 
patient  was  returned  to  the  supine  position.  A  number  of  adhesions  to  the  right  side 
of  the  parietal  peritonaeum  and  ascending  colon  were  divided  between  several  double 
mass  ligatures  of  silk.  Short  pedicle  was  similarly  secured.  Toilet  of  peritonasum; 
closure  of  incision.  Moderate  elevations  of  the  temperature.  Uninterrupted  healing 
of  wound.  Noveinber  15th. — Abscess  of  right  groin  was  incised.  Three  silk  ligatures 
were  discharged.  August  11,  1882. — Patient  died  of  an  intercurrent  disease  not  con- 
nected with  ovariotomy. 

Case  III. — Mrs.  Lena  Dochtermann,  aged  thirty-nine,  multipara.  Very  large 
multilocular  cyst  of  right  ovary.  General  condition  very  poor;  chronic  bronchial 
catarrh  and  chronic  enteritis,  with  diarrhoea,  ascites,  and  anasarca.  April  19,  1886. — 
Ovariotomy.    Extensive  adhesions  of  cyst  to  anterior  and  lateral  parletes ;  to  transverse 


SPECIAL  APPLICATION  OF   THE  ASEPTIC  METHOD.        149 


colon,  omentum,  and  the  bladder.  A  large  number  of  mass  ligatures  were  made. 
Haemorrhage  insignificant.  Duration  of  operation  two  hours  and  a  half.  Patient  died 
in  collapse  seven  hours  after  the  completion  of  the  operation,  temperature  remaining 
subnormal  to  the  last. 

Cysts  of  the  broad  ligament  generally  present  great  difficulties  on  account 
of  their  situation  between  tlie  peritoneal  folds  of  the  ligament.  If  they 
extend  low  down  into  the  small  pelvis,  their  dissection  is  occasionally  im- 
practicable, and  always  very  difficult.  The  utmost  circumspection  and  care 
must  be  exercised  not  to  provoke  haemorrhage  by  injuring  large  veins  in  the 
bottom  of  the  wound,  and  all  adhesions,  not  yielding  to  gentle  blunt  dissec- 
tion with  the  fingers,  must  be  fashioned  into  suitable  masses,  doubly  tied 
with  Thiersch's  spindles,  and  then  divided.  In  cases  baffling  the  skill  or 
enterprise  of  the  surgeon,  the  sac  should  be  properly  trimmed  and  stitched 
to  the  skin,  so  as  to  convert  it,  if  possible,  into  an  extra-peritoneal  recess. 
Drainage  of  the  sac  is  indispensable. 

Case  IV. — ^Mrs.  Ethel  D.,  aged  twenty-one,  nullipara.  Rather  immovable  cjst  of 
the  right  broad  ligament  of  the  size  of  a  child's  head.  Ajyril  6,  1887. — Ovariotomy. 
Incision  five  inches  long.  The  cyst  had  dissected  its  way  out  from  between  the  folds 
of  the  broad  ligament,  and  had  pushed  away  the  parietal  peritonaeum  of  the  anterior 
abdominal  wall  on  the  right  side  to  such  an  extent  as  to  remain  entirely  extra-peritoneal. 
The  sac  was  tapped  and  emptied,  then  it  was  easily  separated  from  its  attachments  by 
blunt  preparation.  About  one  fourth  of  a  square  foot  of  peritonasum  was  detached. 
Finally,  the  pedicle  was  reached,  secured  in  three  ligatures  carried  through  by  means 
of  Thiersch's  spindles,  tied,  and  cut  off".  The  cavity  was  mopped  out  with  corrosive- 
sublimate  lotion,  drained  by  two  ordinary  rub- 
ber tubes,  and  the  external  wound  united  and 
dressed  in  the  usual  manner.  April  7th. — 
Nothing  alarming  had  occurred,  the  tempera- 
ture ranging  about  99°  Fahr.  April  8th. — 
Temperature  101  "o"  Fahr.,  with  a  good  deal  of 
tympanites  and  dyspnoea.  Pulse  of  varying  in- 
tensity and  rhythm,  about  125  beats  per  minute, 
and  rather  weak.  The  outer  bandage  had  to  be 
loosened,  and  energetic  stimulation  by  hourly 
enemata,  consisting  of  one  ounce  of  brandy  and 
two  ounces  of  warm  water,  were  administered, 
till  the  pulse  became  decidedly  fuller  and  more 
regular.  Apjril  10th. — Some  flatus  passed  spon- 
taneously, the  meteorism  diminished  markedly, 
and  the  temperature  fell  to  the  normal  standard. 
April  11th. — Patient  consumed  a  few  oysters 
and  a  little  champagne,  her  nourishment  hav- 
ing consisted  until  then  of  milk  and  lime-water. 
On  the  same  date  slight  uterine  and  vesical 
haemorrhage  was  noted.  The  former  may  have 
been  dependent  upon  subinvolution  remaining  behind  after  a  recent  miscarriage  ;  the 
vesical  haemorrhage  seems  to  have  been  due  to  detachment  of  the  superior  and  lateral 
vesical  wall  during  dissection.  April  13th. — A  saline  laxative  was  administered,  caus- 
ing some  nausea  and  vomiting  with  a  good  deal  of  griping,  but  resulting  in.  three  copi- 


PiG.  117. — Diagram  of  cyst  of  the  broad 
ligament.     (Case  IV.) 


150  RULES  OF   ASEPTIC  AND  ANTISEPTIC  SUHGEKY. 

ous  stools.  The  same  day  the  drainage-tubes  were  shortened.  Tlie  wound  was  found 
healed  by  adhesion  except  where  the  tubes  lay.  Three  of  the  plate  and  shot  sutures 
were  also  removed,  and  two  were  left  behind.  The  catgut  sutures  had  been  all 
absorbed.  April  18th. — The  tubes  were  entirely  withdrawn  and  remaining  sutures 
removed.  April  20th. — The  patient  left  the  bed  tiie  first  time.  April  25th. — The 
wound  was  entirely  healed.     (Fig.  117.) 

It  seems  that  the  extensive  detachment  of  the  peritonaeum  from  its 
nutrient  vessels  led  to  a  grave  disturbance  of  its  circulation,  and  perhaps  to 
partial  {aseptic)  necrosis.  An  adhesive  peritonitis  of  the  intestinal  invest- 
ment apposed  to  the  denuded  parietal  peritoneum  was  set  up,  causing 
paralysis  of  the  muscular  layer  of  the  gut  with  meteorism.  As  soon  as  the 
devitalized  parts  of  the  peritonaeum  were  enveloped  by  fresli  exudations,  the 
irritation  ceased. 

p.  Removal  of  Uterine  Appendages. — The  extension  upward  of  .septic 
conditions  from  the  external  female  genital  organs  often  leads  to  the  estab- 
lishment of  acute  or  chronic  inflammatory  processes  in  and  around  the 
uterine  appendages,  causing  a  train  of  febrile  and  painful  disturbances, 
which  are  so  little  influenced  by  general  and  topical  treatment  that  their 
cure  requires  eradication  by  laparotomy.  Though  in  most  cases  the  diag- 
nosis of  salpingeal  or  ovarian  disturbances  will  meet  wdth  no  serious  difli- 
culty,  occasionally  nothing  short  of  an  exploratory  section  can  shed  light 
upon  the  nature  of  the  affection.  A  comparatively  short  incision  will  usu- 
ally be  found  adequate  for  the  removal  of  the  uterine  appendages,  which,  as 
is  now  well  known,  can  be  easily  and  safely  shelled  out  of  their  adhesions 
by  the  tips  of  the  fingers  (Tait).  Occasionally  a  tube  or  a  parovarian  or 
ovarian  abscess  will  be  ruptured,  and  its  contents  will  escape  into  the  peri- 
toneal cavity.  In  this  case,  the  peritonaeum  has  to  be  thoroughly  flushed 
with  hot  Thiersch's  solution  or  boiled  hot  water.  A  long,  stiff  drainage- 
tube  of  large  caliber  is  connected  with  a  funnel,  and  is  placed  successively 
well  down  into  Douglas's  pouch  and  the  lumbar  recesses.  While  the  hot 
solution  is  gradually  poured  in,  the  index  and  middle  fingers  are  gently 
moved  about  among  the  coils  of  intestine,  so  that  all  the  peritoneal  surfaces 
should  receive  the  benefit  of  the  cleansinor  irrigation.  When  the  fluid  is 
seen  returning  in  a  limpid  state,  irrigation  may  be  stopped.  The  pedicle 
of  the  appendages  is  transfixed  and  tied  off  in  the  usual  manner,  the  peri- 
tonaeum is  mopped  out  dry,  and  the  wound  is  closed. 

Case. — Mrs.  Hannah  M.,  aged  twenty-three,  unipara.  Repeated  attacks  of  severe 
local  peritonitis  in  left  parametrium,  with  high  fever  and  rigors,  appearing  after  child- 
birth in  1888.  May  2,  1889. — A  dead  foetus  of  three  months  was  expelled.  December 
10, 1889. — During  a  sharp  attack  of  local  peritonitis,  the  temperature  rising  to  104" 
Fahr.,  a  painful  immovable  tumor  was  made  out  to  the  left  side  of  the  uterus.  Lapa- 
rotomy, December  19,  1889.  at  Mount  Sinai  Hospital.  The  left  enlarged  ovary,  con- 
taining an  abscess  of  new  formation,  and  the  left  tube  much  thickened  and  distended 
by  pus,  were  enucleated  from  a  mass  of  adhesions,  tied  off  and  removed.  The  ap- 
pendages of  the  right  side  were  found  in  a  normal  state.  Cessation  of  febrile  and 
painful  symptoms.  Intramural  abscess,  delaying  the  discharge  of  the  patient  till  Janu- 
ary 25,  1890. 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.        151 

In  view  of  the  great  index  of  mortality  following  supra-vaginal  hysterec- 
tomy for  uterine  fibroma,  the  removal  of  the  uterine  appendages,  to  induce 
menopause  and  subsequent  shrinkage  of  the  enlarged  uterus,  seems  to 
deserve  attention  and  faithful  trial.  The  operation  is  often  rendered  diffi- 
cult by  the  presence  of  enormously  dilated  veins  surrounding  the  append- 
ages, the  management  of  which  demands  great  care  and  circumspection. 
Being  raised  out  of  the  pelvis  by  the  growth,  the  ovaries  and  tubes  usually 
occupy  a  high  position,  hence  are  found  to  be  rather  accessible.  But  when 
the  fibromatous  uterus  is  very  large,  a  long  incision  will  nevertheless  be 
needed,  to  enable  the  surgeon  to  evert  first  one  then  the  other  side  of  the 
organ,  in  order  to  reach  the  annexa. 

Case. — Mrs.  Susan  M.,  multipara,  aged  thirty-nine,  noticed  abdominal  enlargement 
since  four  years.  Normal  menstruation.  Good  general  condition,  lier  only  complaint 
being  the  size  of  the  belly  and  increasing  dyspnoea.  March  13,  1889. — Girth  thirty- 
eight  and  a  half  inches,  the  apex  of  the  solid,  smooth,  and  fi'eely  movable  tumor 
reaching  about  two  inches  above  the  navel.  January  S3, 1890. — Girth  forty-one  inches, 
the  apex  of  the  tumor  reaching  nearly  to  the  ensiform  cartilage.  In  view  of  the 
absence  of  haemorrhages,  there  being  no  vital  indications  present,  ablation  of  the  uter- 
ine appendages  was  recommended  in  preference  to  supra-vaginal  hysterectomy.  Lungs, 
kidneys,  and  heart  were  found  normal.  March  i,  1890. — Removal  of  uterine  append- 
ages at  Mount  Sinai  Hospital.  Incision  of  eleven  inches  in  length,  to  enable  the  operator 
to  expose  first  one  then  the  other  side  of  the  uterus.  The  intestines  were  not  seen  at  all. 
Difficult  isolation  of  appendages  on  account  of  enormously  distended  veins.  Rather 
high  temperatures  followed  the  operation,  accompanied  by  a  very  conspicuous  shrink- 
ing of  the  tumor,  and  by  the  appearance  of  a  copious,  dark,  sanguinolent  discharge 
from  the  uterus.  The  vagina  was  regularly  irrigated  and  kept  plugged  with  iodoform 
gauze.  A  week  after  the  operation  an  intramural  abscess  was  opened.  The  bowels 
were  moved  on  the  third  day.  The  fever  persisted  for  nearly  four  weeks,  then 
gradually  diminished,  to  disappear  entirely  by  the  beginning  of  April.  On  the  24th  of 
this  month  patient  was  discharged  convalescent,  with  good  appetite,  sound  sleep,  and 
no  pain,  the  granulating  wound  still  open,  but  healing  rapidly.  The  tumor  had 
shrunk  to  about  one  half  of  its  former  size, 

y.  Supra-vaginal  hysterectomy  for  large  myo-fibroma  of  the  uterus 
may  be  indicated  either  by  profuse  loss  of  blood  at  the  menstrual  epoch, 
or  by  other  causes,  rendering  the  patient's  life  unendurable.  An  operation 
should  be  determined  on  only  after  a  faithful  trial  of  less  incisive  reme- 
dies known  to  induce  involution  of  uterine  fibromata  has  plainly  failed  to 
give  relief. 

The  preparations  for  the  operation  are  to  made  with  all  possible  care 
directed  to  the  avoidance  of  septic  infection.  Hsemorrhage  is  to  be  pre- 
vented by  the  application  of  single  or  double  mass  ligatures  to  the  uterine 
adnexa  on  both  sides  of  the  uterus,  and  a  stout  elastic  cord  to  the  cervix. 
Under  favorable  conditions  (that  is,  when  the  cervix  forms  a  slender  pedi- 
cle to  the  otherwise  movable  womb),  the  application  of  double  ligatures  can 
be  obviated  by  cutting  off  the  blood-supply  of  the  organ  from  all  sides  by 
two  continuous  lines  of  mass  ligatures  converging  from  the  free  margin  of 
the  adnexa  toward  the  cervix.     A  suitable-sized  mass  is  first  formed  at  the 


152 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


Fig. 


118. — Diagram  showing  the  arrangement  of  mass  ligatures  in 
supra-vaginal  hysterectomy. 


margin  of  the  broad  ligament  by  means  of  Thiersch's  spindle,  and  is  tied 
off  with  strong  catgut  or  silk.  A  second  mass  adjoining  the  first  one  is 
now  isolated,  and  the  thread,  being  carried  around  it  and  back  through  the 
aperture  made  for  the  application  of  the  first  ligature,  is  firmly  knotted. 

A  third  mass  is  iso- 
lated by  Thiersch's 
spindle,  and  the 
thread  is  carried 
back  through  the 
hole  made  for  the 
isolation  of  the  ad- 
jacent mass,  and  the 
application  of  the 
preceding  ligature. 
Thus  the  cervix  will 
be  soon  reached. 
AVhile  an  assistant 
raises  the  tumor  well  above  the  pelvis,  an  elastic  ligature  is  thrown  around 
the  elongated  cervix  ;  being  tightened,  it  is  secured  by  a  stout  pedicle- 
clamp.  This  stejj  will  have  completed  the  isolation  of  the  uterus,  which 
can  be  now  exsected  without  loss  of  blood,  the  line  of  section  being  carried 
just  outside  of  the  chain  of  ligatures.      (Fig.  118.) 

Witli  increasing  experience  the  intraperitoneal  treatment  of  the  uterine 
stump  is  more  and  more  abandoned  in  favor  of  the  extraperitoneal  method, 
which  is  undoubtedly  much  safer.  The  stumjD  is  crucially  transfixed  with 
two  long  shawl-pins  on  the  distal  side  of  the  elastic  ligature,  and  as  much 
of  its  mass  as  can  be  safely  removed  is  gradually  pared  away.  The  upper 
portion  of  the  abdominal  wound  is  closed  in  the  usual  manner.  Then,  the 
stump  being  suitably  adjusted  in  the  lower  angle  of  the  wound,  its  perito- 
neal covering,  situated  on  the  proximal  side  of  the  ligature,  is  attached  to 
the  parietal  jDeritonaeum  by  a  number  of  interrupted  catgut  stitches  all 
around  its  circumference,  thus  shutting  off  the  peritoneal  cavity  from  fur- 
ther contamination.  The  raw  surface  of  the  stump  is  either  seared  with 
the  thermo-cautery  and  dusted  with  iodoform,  or  painted  with  some  per- 
chloride  of  iron  solution  and  then  dressed  in  the  usual  manner.  The 
stump  will  shrink  considerably  within  two  or  three  da3's,  and  the  ligature 
can  be  removed  on  the  fifth  day.  The  slough  will  come  away  in  about  a 
week  or  ten  days,  and  the  remaining  granulating  surface  will  heal  in  from 
four  to  six  weeks. 

In  the  presence  of  adhesions,  or  a  broad  implantation  of  the  myoma 
into  the  deeper  parts  of  the  pelvis,  the  same  rules  of  dissection  are  to  be 
heeded  that  have  been  elucidated  in  a  former  jiaragraph  relating  to  abdomi- 
nal tumors. 

The  author's  only  case  of  supra-vaginal  hysterectomy  ended  fatally  by 
septicaemia.  The  sources  of  infection  were  presumably  the  sponges,  man- 
aged by  two  raw  nurses  at  Mount  Sinai  HosiDital. 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.         153 

Case. — Mrs.  S.  Levy,  aged  thirty-three,  multipara.  Very  large  fibro-myoma  of  the 
corpus  uteri.  Severe  metrorrhagia  at  each  menstruation,  with  increasing  anaemia  and 
great  helplessness  from  the  size  of  the  tumor.  June  7,  1883. — Hysterectomy  at  Mount 
Sinai  Hospital.  Incision  six  inches  long.  Easy  deligation  of  adnexa  in  tvs^o  rows  of 
mass  ligatures ;  elastic  ligature  of  cervix  ;  ablation  of  the  tumor  and  adnexa.  Searing 
of  the  surface  of  the  small  stump  by  thermo-cautery.  The  smallness  of  the  stump 
induced  the  author  to  treat  it  like  an  ovarian  pedicle,  and  it  was  replaced  in  the  abdomi- 
nal cavity  after  securing  of  the  elastic  ligature  by  a  knot  of  strong  silk.  Hardly  any 
blood  was  lost,  and  a  smooth  course  of  healing  was  expected.  But  all  hopes  were 
shattered  by  the  development  of  septic  symptoms  in  the  night  following  the  operation. 
June  8th. — High  fever,  retching,  and  sharp  abdominal  pain  were  present,  but  no  signs 
of  peritonitis  could  be  made  out.  Twenty-nine  hours  after  the  operation  the  patient 
died  in  coma.  Post-mortem  examination  revealed  an  abscess  of  the  abdominal  wall 
in  the  line  of  suture,  and  a  grayish  discoloration  of  the  peritonseum  near  the  elastic 
ligature.  A  few  drachms  of  turbid,  bloody  serum  were  found  in  Douglas's  pouch. 
No  sign  of  peritonitis. 

Investigation  showed  that  during  the  operation  the  management  of  the 
sponges  by  the  nurses  had  been  a  careless  one ;  that  a  too  large  number  of 
persons  were  intrusted  with  the  care  of  the  sponges.  The  practical  out- 
come of  this  experience  was  the  order  that  the  sponges  should  be  attended 
to  by  one  person  only,  and  that  this  person  should  always  be  the  most  expe- 
rienced and  reponsible  one  of  the  available  number. 

The  preceding  case  shows  that  fatal  septiceemia  may  be  induced  by  in- 
fection of  the  peritonseum,  and  yet  purulent  peritonitis  may  be  absent. 
Perhaps  there  was  not  enough  time  for  the  development  of  peritonitis. 

Many  rapidly  fatal  cases,  classed  by  various  surgeons  under  the  head- 
ing of  ^'^ shock,''  or  "exhaustion,"  would,  on  closer  inquiry,  turn  out  to  he 
cases  of  acute  septiccemia. 

8.  Nephrectomy  by  abdominal  section  is  justified  in  cases  of  degenerated 
floating  kidney  when  the  urine  gives  sufficient  evidence  of  chronic  pyo- 
nephrosis with  or  without  stone. 

Case. — Mrs.  S.  Weissenstein,  aged  forty-six.  Noticed  fourteen  years  ago  a  mova- 
ble painless  lump  in  her  right  hypochondrium.  Since  about  nine  months  very  acute 
symptoms  of  cystic  trouble  set  in,  and  the  lump  became  larger  and  painful.  Constant 
desire  to  urinate,  continuous  fever,  with  occasional  rigors,  and  large  quantities  of  pus 
in  the  urine  brought  her  to  a  very  low  state.  A  smooth,  hard,  kidney-shaped  movable 
tumor  of  the  size  of  a  large  man's  fist  could  be  felt  in  the  right  hypochondriac  region. 
January  11,  1887. — Examiaation  under  chloroform.  TJie  left  Mdney  could  not  ie 
made  out  distinctly.  The  urine  was  scanty  and  acid,  amounting  to  about  twenty  ounces 
per  day,  of  the  consistency  of  cream,  and  contained  very  large  quantities  of  pus.  Janu- 
ary 15th. — Abdominal  nephrectomy  at  the  German  Hospital.  The  tumor  being  ex- 
posed, the  hand  was  slipped  into  the  left  lumbar  part  of  the  peritoneal  cavity,  when 
the  left  Mdney  could  he  distinctly  felt.  After  this  the  peritongeura  and  its  capsule  were 
split  along  the  whole  anterior  aspect  of  the  enlarged  kidney,  and  the  organ  was  easily 
peeled  out.  A  pedicle  was  formed  of  the  ureter  and  vessels,  and  was  tied  off  in  two 
masses.  After  the  removal  of  the  tumor,  the  large  retro-peritoneal  cavity  was  carefully 
mopped  out  and  loosely  packed  with  strips  of  iodoformed  gauze.  These  were  brought 
out  near  the  upper  angle  of  the  abdominal  wound.     The  edges  of  the  incision  through 


154  RULES  OF  ASEPTIC  AXD  ANTISEPTIC  SURGERY. 

the  posterior  lamella  of  the  peritonseuni  and  the  renal  capsule  were  stitched  to  the 
peritoneal  linintr  of  the  anterior  abdominal  wall.  The  outer  wound  was  united  in  the 
usual  way.  The  patient  lost  very  little  blood,  but  during  the  operation  threatening 
heart-weakness  necessitated  the  subcutaneous  exhibition  of  camphor  and  whisky.  She 
rallied  pretty  well,  and  passed  some  perfectly  clear  urine  shortly  after  the  operation. 
January  16th. — Temperature,  100°  Fahr.  Patient  cheerful,  and  suffering  very  little 
pain.  Urine  continues  clear  and  very  concentrated.  In  the  night  several  fainting- 
spells.  The  night  nurse  did  not  pay  sufScient  attention  to  the  patient,  who  died  in  a 
fit  of  syncope  early  in  the  morning  of  January  17th.  Post-mortem  examination  failed 
to  show  any  morbid  change  aside  from  the  abdominal  wound,  which  was  found  dry, 
and  jast  as  fresh  as  at  the  time  of  the  operation.  With  more  untiring  stimulation,  the 
patient  might  have  survived.  The  enlarged  right  kidney  had  lost  its  textural  charac- 
ter, and  was  converted  into  an  irregular  sinuous  bag.  containing  six  uratic  stones  of 
various  sizes,  surrounded  by  a  quantity  of  pus. 

c.  Gastrostomy. — Impassable  cicatricial  stenosis  of  the  cesopliagus  is  a 
very  strong  indication  for  the  establishment  of  a  gastric  fistula.  Threat- 
ening starvation  will  be  thns  averted,  and  an  opportunity  will  at  the  same 
time  be  created  for  attempting  retrograde  catheterism  of  the  oesophagus, 
which  may  succeed. 

Case. — Hedwig  Meyer,  aged  twenty-four.  Cicatricial  impassable  stricture  of  the 
oesophagus  twelve  inches  from  incisors,  caused  by  swallowing  pure  carbolic  acid. 
Liquids  only  could  be  swallowed,  with  frequent  regurgitations.  Extreme  emaciation. 
April  17.  1886. — Gastrostomy  at  the  German  Hospital.  Immediately  below  and  par- 
allel with  the  left  costal  arch,  an  incision  of  two  and  a  half  inches  exposed  tiie  perito- 
naeum. After  stanching  the  slight  haemorrhage,  the  peritonaeum  was  incised,  and 
the  edges  of  the  peritoneal  incision  were  taken  up  by  four  artery  forceps.  The  left 
lobe  of  the  liver  wa.s  found  presenting.  This  being  pushed  aside,  the  anterior  waU  of 
the  empty  stomach  came  in  view,  and  was  withdrawn  from  the  wound  with  a  pair  of 
thumb-forceps.  The  cardiac  portion  of  the  organ  was  drawn  well  into  the  wound,  and 
was  transtixed  with  a  Peaslee's  needle  to  prevent  its  slipping  back.  The  peritoneal 
covering  of  the  stomach  was  stitched  to  the  everted  edges  of  the  parietal  peritonaeum 
by  two  tiers  of  interrupted  silk  sutures.  The  artery  forceps  were  of  very  great  service 
in  securing  the  apposition  of  broad  peritoneal  surfaces.  The  external  wound  was 
packed  with  iodoforraized  gauze,  and  dressed  antiseptically.  No  reaction  following, 
the  packing  was  removed  on  April  20th,  and  the  Peaslee's  needle  was  withdrawn. 
After  this  an  incision  one  half  inch  long  was  made  into  the  stomach,  and  a  short  piece 
of  stout  drainage-tube  snugly  fitting  into  the  aperture  was  placed  in  the  stomach,  and 
was  secured  from  slipping  in  by  a  large  safety-pin.  Its  opening  was  closed  by  a  cork 
sto[iper.  Previous  to  this  the  lips  of  the  mucous  membrane  were  stitched  to  the  outer 
skin.  From  this  date  on  daily  attempts  were  made  to  pass  the  stricture  with  a  sound, 
introduced  into  the  oesophagus  from  below,  through  the  gastric  wound.  May  13th. — 
Dr.  Bachmann.  the  house-surgeon,  succeeded  in  passing  from  below  an  elastic  catheter 
armed  with  a  mandrel  through  the  stricture.  Milk  injected  into  the  catheter  made  its 
appearance  in  the  fauces.  May  IJ^th. — A  small-sized  sound  was  passed  from  above. 
Alimentation  was  carried  on  both  artificially  through  the  drainage-tube  placed  in  the 
stomach,  and  by  the  mouth.  Gradually,  as  the  ability  to  swallow  solids  returned,  more 
and  more  food  was  taken  by  the  mouth,  and  the  drainage-tube  was  withdrawn  from 
the  stomach.  The  gastric  fistula  closed  spontaneously  by  the  end  of  June.  August 
26th. — Patient  was  discharged,  with  directions  to  continue  the  use  of  the  oesophageal 
bougie. 


SPECIAL  APPLICATION   OF  THE   ASEPTIC   METHOD.         I55 

In  cases  of  cancer  of  the  cesophagus,  gastrostomy  does  not  yield  favorable 
results.  Of  eight  cases,  mostly  men  past  middle  age,  and  all  presenting  the 
picture  of  more  or  less  extreme  emaciation,  five  died  in  a  few  (all  within 
twelve)  hours  after  the  operation.  The  slight  depression  of  the  heart's  action 
by  angesthesia  was  sufficient  to  induce  fatal  collapse.  The  sixth  case  sur- 
vived the  operation  for  thirty-two  days,  but  was  losing  ground  steadily  in 
spite  of  artificial  feeding  by  the  tube  placed  in  the  stomach.  A  great  deal  of 
difficulty  was  experienced  in  this  case  on  account  of  the  considerable  leakage 
that  was  taking  place  alongside  of  the  tube.  Apparently  the  incision  had 
been  made  too  large,  and  gastric  juice  was  escaping  in  varying  quantities 
into  the  dressings.  The  gradual  emaciation  and  final  dissolution  were  in  a 
great  measure  due  to  this  constant  loss  of  albuminoid  substances. 

In  two  cases  the  operation  brought  about  a  very  marked  improvement 
in  the  patient's  condition.  Both  gained  in  weight  and  strength,  the  weight 
of  one  increasing  twelve  pounds  in  four  weeks  after  gastrostomy.  One  sur- 
vived the  operation  for  seven,  the  other  for  five  months. 

The  outer  dressings  of  a  gastrostomy  wound  are  arranged  in  the  follow- 
ing manner  :  A  split  compress  of  iodoformized  gauze,  similar  to  that  used 
in  tracheotomy  dressings,  is  slipped  in  under  the  safety-pin  holding  the 
drainage-tube,  and  is  arranged  around  the  same.  A  piece  of  rubber  tissue, 
or  sheet  rubber,  somewhat  larger  than  the  gauze  compress,  is  provided  with 
a  not  too  large  slit  in  its  middle,  which  then  is  also  slipped  on  the  end  of 
the  tube  by  being  passed  first  over  one,  then  over  the  other  end  of  the  pin. 
The  rubber  should  fit  snugly  to  the  tube.  Over  this  is  laid  a  succession 
of  two  or  more  sublimate-gauze  compresses  of  increasing  size,  each  pro- 
vided with  a  slit  for  the  passage  of  the  corked-up  end  of  the  rubber  tube. 
The  safety-pin,  which  was  underpadded  by  the  iodoformed  gauze  and  rub- 
ber sheet,  is  covered  up  by  the  subsequent  compresses,  which  are  snugly 
bandaged  to  the  trunk.  Over  the  outer  bandage  another  apron  of  rubber 
tissue  is  pinned,  the  rubber  tube  projecting  from  a  slit  in  its  middle.  The 
object  of  this  is  to  protect  the  bandage  from  soiling  by  regurgitant  food. 

Feeding  is  to  be  done  at  first  in  short  intervals  ;  later  on,  larger  quan- 
tities of  food  can  be  introduced  m  four  daily  doses. 

d.  Colotomy. — Eectal  obstruction,  most  commonly  by  syphilis  or  cancer, 
is  an  accepted  indication  for  the  establishment  of  an  artificial  anus,  either  in 
the  groin  or  in  the  loin.  Lumbar  and  inguinal  colotomy  each  has  special 
advantages  and  drawbacks,  the  consideration  of  which  must  determine  the 
choice  of  the  method  preferable  in  a  given  case.  While  lumbar  section  is 
extra-peritoneal,  nevertheless  injury  to  the  peritongeum  is  very  apt  to  occur; 
finding  of  the  colon  is  not  easy  ;  sometimes  it  is  impossible  without  opening 
the  peritonaeum,  notably  when  there  is  a  well-developed  mesocolon.  The 
shape  of  the  artificial  anus  after  the  lumbar  operation  is  mostly  excellent  on 
account  of  the  ample  mass  of  tissues  traversed  by  the  fistula ;  but  the  situa- 
tion of  the  aperture  is  unhandy,  the  patients  generally  requiring  the  aid  of 
a  second  person  for  cleaning  and  dressing  the  artificial  anus. 

Inguinal  colotomy  is  a  short  and  easy  operation,  and  provides  for  an 
22 


156  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

opening  located  accessibly  for  the  manipulations  of  the  patient  in  cleaning 
and  dressing  tlie  aperture.  Its  drawbacks  are  the  necessity  of  incising  the 
peritona?um — a  circumstance  which  has  lost  most  of  its  terrors  since  the 
introduction  of  the  aseptic  method — and  the  tendency  to  troublesome  pro- 
lapse of  the  intestinal  mucous  membrane.  The  latter  difficulty  can  be 
overcome  by  proper  management. 

(a)  Lumbar  colotomy. — Finding  of  the  posterior  as2:)ect  of  the  colon  is 
very  much  facilitated  by  insufflation  of  the  thick  gut.  This  can  be  done 
either  by  a  bellows  attached  to  a  soft  catheter  passed  in  beyond  the  stricture, 
or  by  the  similar  employment  of  a  siphon  bottle  filled  with  mineral  water 
charged  with  carbonic  acid.  The  mouth  of  the  siphon  is  connected  with 
the  catheter  by  a  piece  of  rubber  tubing,  then  the  sijihon  is  inverted  and 
the  valve  is  opened.  The  carbonic-acid  gas,  collecting  about  the  end  of  the 
glass  tube  reaching  to  the  bottom  of  the  bottle,  escapes  into  the  gut,  and  pro- 
duces a  visible  bulging  of  the  colon. 

When  the  stricture  is  impassable  and  inflation  not  practicable,  recogni- 
tion of  the  colon  may  offer  great  difficulty.  The  landmarks  are  the  kidney 
above,  and  the  reflexion  of  the  peritonseum  externally,  but  occasionally  they 
are  of  little  practical  use. 

Case  I. — Mrs.  C.  O.,  aged  fifty-six.  Very  extensive  far-jrone  cancer  of  the  rectum 
with  involvement  of  the  uterus.  The  stricture  was  very  long  and  impassable.  June  25, 
1882. — Lumbar  colotomy  was  attempted.  Though  the  kidney  and  the  reflexion  of  the 
peritoneum  were  clearly  discerned,  the  incision  opened  the  peritonaeum,  and  the  pro- 
truding gut  turned  out  to  be  small  intestine.  The  poor  condition  of  the  patient  made 
further  prolongation  of  anaesthesia  undesirable,  therefore  the  gut  was  attached  to  the 
skin  and  incised.  The  wound  healed  promptly,  giving  much  relief,  but  the  patient 
died  four  weeks  after  the  operation  from  emaciation,  due  in  part  to  insufficient  nutri- 
tion caused  by  the  high  position  of  the  intestinal  aperture.  Post-mortem  examination 
showed  that  the  intestinal  fistula  was  midway  between  the  stomach  and  ctecum. 

Case  II. — Mrs.  Mary  Brunner,  aged  forty-three.  August  23, 1885. — Lumbar  coloto- 
my at  Mount  Sinai  Hospital  under  ether.  August  2Jfth,  25th. — Acute  lobar  pneumonia 
of  the  entire  right  lung,  to  which  the  patient  succumbed.  The  colotomy  wound  had 
closed  by  primary  adhesion.  Presumably  the  pneumonia  was  caused  by  the  entrance 
of  foul  oral  secretions  into  the  right  bronchus  during  the  operation. 

{h)  Inguinal  colotomy. — A  vertical  incision  is  preferable  to  one  parallel 
with  Poupart's  ligament.  With  the  former,  the  fibers  of  the  oblique 
muscles  will  be  cut  across  their  course  and  will  retract,  giving  ample  space 
for  a  clear  insight  and  free  manipulation.  Asepticism  has  to  be  maintained 
as  in  all  abdominal  operations  mainly  by  scrupulous  cleanliness. 

The  peritonaeum  is  sufficiently  incised  to  grasp  the  presenting  colon  with 
the  fingers  for  withdrawal,  and  its  edges  are  secured  with  four  artery -forceps. 
The  gut  will  be  known  by  its  taeniae  and  the  epiploic  appendices.  A  loop 
about  four  inches  in  length,  having  neither  a  too  long  nor  too  short  meso- 
colon, is  withdrawn,  and  its  mesial  and  distal  halves  are  stitched  to  each 
other  in  front  and  in  the  rear  so  as  to  cause  the  formation  of  a  spur  (a  b. 
Fig.  120).  The  sutures  are  made  with  an  ordinary  straight  sewing-needle, 
the  suturing  material  being  catgut  No.   3.      The  stitches  should  include 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.        157 

only  the  peritoneal  covering  of  the  intestine.     The  loop  is  then  dropped 
back  into  the  peritoneal  incision,  and  its  sides  are  stitched  to  the  parietal 
peritonfenm  all  round  with  two  tiers  of  catgut  sutures.      In  doing  this 
the  parietal  peritoneum  can  be  well  everted  by  the  artery- 
forceps  attached  to  it,  and  a  broad  surface  of  contact 
between  it  and  the  gut  can  be  thus  secured.     Finally, 
the  gut  is  transversely  incised  and  the  intestinal  mucous 
membrane  is  sewed  to  the  outer  skin.     To  prevent  pro- 
lapse of  the  mucous  membrane,  a  loop  of  gut  is  to  be 
selected  that  has  a  mesocolon  of  not  greater  length  than      /      /  ^  \ 
just  to  permit  its  easy  approximation  to  the  parietes,      Fia.  120.  —  Forma- 
The  formation  of  the  spur  as  suggested  by  Verneiiil  has        g'Sliiai  cobtomv^' 
this  advantage,  that  fecal  matter  will  not  find  its  way 
into  the  lowest  part  of  the  rectum  situated  below  the  artificial  anus,  and 
thus   painful   and    otherwise   disagreeable   regurgitation  of  fseces  will   be 
avoided.     At  the  same  time,  secretions  forming  in  the  distal  section  of  the 
rectum  will  not  be  retained,  but  can  escape  through  the  fistula. 

The  proposition  of  completely  dividing  the  loop  of  extracted  colon,  sew- 
ing the  upper  end  into  the  wound,  and  closing  by  suture  and  dropping  back 
the  distal  end,  is  feasible,  but  is  met  by  a  serious  objection.  The  stricture 
may  lead  to  complete  occlusion,  and  the  secretions  of  an  ulcerated  cancer 
may  so  distend  the  closed  gut  as  to  lead  to  rupture  of  the  sutured  part  and 
to  fatal  peritonitis. 

Case  I, — Mary  Steiger,  aged  fifty-nine.  Extensive  rectal  cancer  with  a  number  of 
periproctitic  abscesses  causing  profuse  purulent  discharge  through  the  anus.  Emaciat- 
ing hectic  fever  and  distressing  fecal  retention.  August  13,  1885. — Inguinal  colotomy 
at  the  German  Hospital.  Ihe  thick  gut  was  withdrawn,  and  was  closed  with  two 
ligatures  of  stout  silk  carried  through  the  mesocolon  by  the  point  of  a  thumb-forceps. 
The  peritoneal  incision  was  covered  with  two  flat  sponges  and  the  gut  was  cut  through 
between  the  ligatures.  A  little  fecal  matter  escaped  and  was  caught  by  the  sponges, 
whereupon  they  were  changed.  The  open  lumen  of  the  gut  was  mopped  out  cleanly, 
and  well  irrigated  with  Thiersch's  solution.  After  this  the  distal  end  of  the  gut  was 
closed  by  two  tiers  of  Lembert  sutures  made  with  catgut,  and  was  returned  to  the 
abdominal  ca\ity.  The  peritoneal  layer  of  the  mesial  end  was  stitched  to  the  parietal 
peritoneum  and  the  mucous  membrane  to  the  outer  skin.  The  patient  rallied  well 
from  the  operation,  but  the  high  fever  and  profuse  discharge  from  the  anus  continued. 
August  18th. — The  patient  died  under  septic  symptoms.  On  autopsy,  the  wound  was 
found  healed  by  the  first  intention,  likewise  the  sutured  distal  end  of  the  gut.  The 
peritoneum  was  normal,  but  a  very  large  retro-peritonael  abscess,  communicating  with 
the  rectal  pouch  above  the  cancer,  extended  high  up  along  the  front  of  the  sacrum,  and 
contained  a  large  quantity  of  extremely  fetid  pus. 

Case  II. — Stephen  Y.,  government  official,  aged  sixty-one.  Far-gone  rectal  cancer, 
with  involvement  of  the  prostate  and  old  strictures  of  the  pendulous  part  of  the 
urethra.  November  15,  1886. — Inguinal  colotomy  with  formation  of  spur  at  Mount 
Sinai  Hospital  under  ether.  November  16th. — Lobular  pneumonia,  probably  caused  by 
aspiration  of  mucus  during  the  anaesthesia.  By  ISTovember  25th  the  acute  febrile 
symptoms  had  subsided,  but  profuse  purulent  sputa  were  continually  expectorated. 
The  bladder  also  caused  much  trouble,  although  the  tight  strictures  had  been  well 


158  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

dilated.  The  urine  contained  much  pus,  later  on  blood,  coming  from  the  ulcerated 
portion  of  the  cancer  occupying  the  neck  of  the  bladder.  The  colotomy  wound  healed 
kindly,  and  a  satisfactory  artificial  anus  had  been  secured.  The  chronic  bronchial 
catarrh,  fetid  cystitis,  and  later  pyelo-nephritis,  however,  hastened  the  death  of  the 
patient,  which  occurred  on  December  23d. 

Aside  from  Case  11,  inguinal  colotomy  with  the  formation  of  a  spur  was 
successfully  performed  by  the  author  for  rectal  cancer  altogether  six  times 
at  Mount  Sinai  Hospital.  The  histories  do  not  present  sufficient  interest 
to  warrant  their  detailed  enumeration.  All  the  patients  were  materially 
improved,  and  survived  the  operation  for  periods  of  from  six  to  eighteen 
months. 

(c)  Excision  and  Suture  of  Gut  {Enterorrliapliy). — The  object  of  enter- 
orrhaphy  is  either  the  repair  of  injuries,  morbid  or  traumatic,  or  the  estab- 
lishment of  a  direct  artificial  communication  between  more  or  less  distant 
sections  of  the  intestinal  tract.  Looked  at  from  the  standpoint  of  antisep- 
ticism,  the  cases  requiring  enterorrhaphy  can  be  roughly  classed  in  two 
divisions,  which  also  fairly  represent  a  corresponding  gradation  of  the  grav- 
ity of  the  procedure. 

First  come  chronic  conditions,  requiring  enterorrhaphy  alone,  as  for 
instance  fecal  fistulge  due  to  a  moderate  amount  of  loss  of  substance  of  the 
wall  of  the  gut.  In  many  of  these,  where  the  loss  does  not  involve  more  than 
one  third  of  the  circumference  of  the  intestine,  liberation  of  the  adherent 
edges,  followed  by  longitudinal  suture,  will  be  found  sufficient.  Longitudi- 
nal suture  in  a  case  where  more  than  one  tliird  of  the  circumference  of  the 
gut  was  lost  would  result  in  stricture.  Hence  in  these  instances  suture  has 
to  be  preceded  by  transverse  excision.  It  may  be  said  that  in  these  cases 
(excepting  those  of  fecal  fistula  in  the  jejunum),  the  patient's  general  con- 
dition being  good  or  fair,  the  time  and  circumstances  of  the  operation  can 
be  selected  and  arranged  so  as  to  render  it  comparatively  safe.  This  state- 
ment is  borne  out  by  a  large  proportion  of  recorded  recoveries. 

Next  we  have  to  mention  as  belonging  to  the  same  division,  tumors  and 
cicatrices  requiring  excision  and  subsequent  enterorrhaphy,  or  the  estab- 
lishment of  an  artificial  interosculation. 

The  second  class  of  cases,  much  more  difficult  to  deal  with,  consists  of 
acute  disturbances,  in  which  enterotomy,  enterectomy,  and  the  various  forms 
of  enterorrhaphy  have  to  be  done  under  an  urgent  and  peremptory  vital 
indication. 

It  would  lead  too  far  to  enter  here  into  a  detailed  consideration  of  all 
the  conditions  belonging  to  this  group,  and  we  must  content  ourselves  with 
a  compendious  enumeration.  Persistent  intestinal  haemorrhage,  the  removal 
of  a  gall-stone  or  foreign  body  impacted  in  the  intestine,  acute  perforation 
of  the  gut  by  an  ulcer,  as  for  instance  in  typhoid  fever  ;  then  rupture 
and  stab  and  gunshot  injuries  of  the  stomach,  small  or  large  intestine  ; 
finally,  necrosis  from  hernial  strangulation,  especially  if  the  site  of  the  lesion 
is  in  the  jejunum.  These  may  require  enterorrhaphy  with  or  without  pre- 
ceding enterotomy  or  enterectomy. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.         159 

It  stands  to  reason  that  in  this  class  of  cases  the  ratio  of  recoveries  can 
not  be  as  favorable  as  in  the  preceding  one.  But,  with  an  increasing  tend- 
ency to  resort  to  early  operative  measures,  and  with  the  imjDrovement  of 
the  technique,  multiplying  successes  offer  decided  encouragement  to  surgi- 
cal enterprise. 

As  enterorrhaphy  is,  either  before  or  after  the  establishment  of  fecal 
fistula,  most  commonly  employed  for  the  repair  of  lesions  due  to  intestinal 
necrosis  from  hernial  strangulation,  the  detailed  consideration  of  the  pro- 
cedure as  adapted  to  this  subject  will  be  selected  as  an  example. 

The  liberation  and  withdrawal  of  the  involved  intestinal  loop  is  the  first 
problem  to  be  solved.  Where  there  is  no  perforation,  and  adhesions  are 
absent,  the  gut  can  be  easily  bronght  out  as  soon  as  the  strangulating  band 
is  divided  :  but,  where  a  fecal  fistula  is  present,  this  step  will  demand  care 
and  attention  to  prevent  infection  of  the  peritousum.  If  the  circumstances 
•of  the  case  were  sucli  as  to  permit  before  the  operation  a  thorough  prepa- 
ration of  the  gut  by  evacuation  and  disinfection,  the  adherent  edges  of  the 
fecal  fistula  can  be  directlv  dissected  otit  tmtil  the  gtit  is  free  to  follow  sren- 
tie  traction.  But  where  preparation  was  impossible,  it  is  safer  to  open  the 
peritoneal  cavity  above  and  near  the  ingtiinal  canal,  exposing  the  involved 
knuckle,  which  will  enable  the  surgeon  to  aj^ply  a  clamp  each  to  the  ascend- 
ing and  descending  part  of  the  loo])  on  both  sides  of  the  lesion,  thus  exclud- 
ing the  possibility  of  accidental  escape  of  fecal  matter.  As  soon  as  the 
knuckle  of  gut  is  liberated,  it  is  freely  withdrawn  from  the  peritoneal  cavity, 
so  as  to  render  the  subsequent  steps  of  the  operation  practically  extra- 
peritoneal. The  extracted  intestine  is  placed  on  a  disinfected  towel  and  the 
abdominal  wound  is  packed  around  the  emerging  and  returning  portions  of 
the  knuckle  with  strips  of  gauze,  to  shut  off  the  peritoneal  cavity.  After 
this  two  temporary  ligatures  consisting  of  pieces  of  well-disinfected  tape  are 
passed  close  to  the  gut  through  its  omentum  at  a  safe  distance  from,  and 
one  above  the  other  below  the  fistula.  Being  safely  knotted,  they  will 
prevent  the  escape  of  intestinal  contents.  The  clamps  are  now  removed,  and 
the  interior  of  the  tied-off  portion  of  the  gut  is  carefully  cleansed  by  irriga- 
tion and  thorough  wiping  out  with  a  small  sponge. 

In  excising  the  damaged  j^art  of  the  viscus,  the  sections  are  made  with 
straight  scissors  at  a  right  angle  to  the  axis  of  the  gut,  good  care  being  taken 
to  carry  them  through  unmistakably  sound  tissues.  Formerly  a  correspond- 
ing wedge-shaped  jjortion  of  the  mesentery  was  also  excised  with  the  intes- 
tinal cylinder,  but  this  detail  has  been  abandoned  as  unnecessary,  and  the 
mesentery  is  spared  as  far  as  it  appears  healthy.  The  bleeding  points  being 
deligated,  the  gap  in  the  mesentery  is  stitched  up  with  catgut,  care  being 
taken  to  bring  about  a  precise  apposition  of  the  mesenteric  attachments 
near  the  intestine. 

In  observing  the  transverse  section  of  the  gut,  it  will  be  seen  that  the  peritoneal  and  mus- 
tiular  layers  having  retracted,  the  mucous  membrane  projects  for  about  an  eighth  of  an  inch.  A 
stitch  passed  through  this  mucous  margin  is  called  Czerny's  suture.  The  stitch  which  without 
penetrating  the  entire  thickness  of  the  intestinal  wall  brings  into  apposition  two  serous  surfaces 


160 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


is  known  as  Lembert's  suture.     The  best  suturing  material  is  fine,  well-disinfected  China  bead 
silk,  threaded  at  eacli  end  through  a  slender,  round  sewing-needle. 

The  intestinal  suture  should  commence  by  m  Czerny  stitch  correspond- 
ing to  the  mesenteric  attachment.  The  stitch  is  closed  so  as  to  leave  the 
knot  on  the  mucous  surface.     After  this  a  Lambert  suture  is  applied  close 


Fig.  120  a. — Loof)  of  small  intestine,  a  b,  Lines  of  section  through  the  gut,  removing  the  gan- 
grenous portion.  b  c,  Same  through  the  mesentery,  a  o,  Gangrenous  portion  of  ileum. 
d  d,  Occlusion  of  the  afferent  and  efferent  tubes  by  tape  ligatures.     (VVyetli.) 

to  one  side  of  the  mesenteric  attachment ;  the  needle,  entering  the  peritoneal 
and  muscular  layers  about  one  eighth  of  an  inch  from  one  margin  of  the 
cut,  and  passing  between  the  peritona3um  and  mucous  membrane  for  about 


Peritoneal  layer. 
Muscular  layer. 
Mucous  membrane. 


-CD- 


Fig.  120  b. 

and  6, 


— Schematic,     a,  Lembert's, 
Czerny's  sutures.     (Wyeth). 


Fig.  120  c. — Schematic.  Showing 
the  inversion  of  the  peritoneal 
layer  by  tying  Lembert's  suture, 
and  of  the  mucous  membrane  by 
Czerny's  suture.     (Wyeth.) 


one  third  of  an  inch,  is  made  to  emerge  again  through  the  peritonifium. 
The  other  end  of  the  same  tliread  is  similarly  passed  through  the  other  mar- 
gin of  the  gut  at  a  point  exactly  corresponding  to  the  first  stitch,  and  this 
suture  is  knotted.  Thus  the  wall  of  the  intestine  will  be  inverted.  The 
intervals  between  the  Lembert  sutures  should  not  exceed  one  fourth,  those 
between  Czerny's  sutures  one  third  of  an  inch.     The  stitching  should  be 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD. 


161 


done  first  on  one  then  on  the  other  side  of  the  mesenteric  attachment, 
Czerny's  stitch  always  preceding  two  or  three  Lembert  sutures,  until  about 
three  quarters  of  the  circumference  of  the  gut  are  united.  The  last  two 
Czerny  stitches  can  not  be  knotted  within  the  lumen  of  the  gut,  the  knots 
remaining  imbedded  between  the  mucous  and  muscular  layers.  To  give 
additional  security  against  leakage,  another  continuous  suture,  comprising 
the  two  external  coats,  is  rapidly  applied  just  outside  of  Lembert's  line  of 
sutures.  When  the  work  of  stitching  is  completed,  the  intestine  is  cleansed 
with  Thiersch's  solution,  and,  the  packing  and  tape  ligatures  being  removed, 
is  dropped  back  into  the  peritoneal  cavity.  As  an  additional  safeguard,  a 
pledget  of  iodoform 
gauze  is  placed  well 
up  against  the  line 
of  sutures,  and  is 
brought  out  at  the 
lower  angle  of  the 
external  wound, 
which  is  closed  in 
the  usual  fashion, 
except  where  the 
gauze  emerges.  An 
aseptic  dressing 

completes  the  pro- 
cedure. An  opiate 
is  administered  and 
food  is  withheld  for 
twenty-four  hours, 
after  which  time 
liquid  nourishment 
can  be  sparingly 
given.  Eectal  ali- 
mentation will  hus- 
band the  patient's 
strength,  and  will 
in  a  measure  con- 
trol thirst.  Under 
favorable  circum- 
stances the  iodo- 
form packing  can 
be  withdrawn  on  the 
third  or  fourth  day. 
Should  leakage  oc- 
cur, it  will  find  its 
way   out   along  the 

track  of  the  pledget        -pia.  120  d.— Senn's  bone  plates  applied  to  colo-colostomy  before 
of  2;auze.  tying  together.     (Abbe.) 


162 


EULES  OF  ASEPTIC  AND   ANTISEPTIC  SURGEEY. 


The  only  seriou?  drawback  to  this  operation  is  the  long  time  consumed  in  applying  the 
stitches.  Senn,  of  Milwaukee,  was  the  first  to  approach  successfully  the  question  of  abbreviating 
the  procedure.  He  suggested,  instead  of  the  large  number  of  interrupted  sutures,  the  use  of 
two  elliptic  decalcified  bone  disks,  each  armed  with  four  silk  threads  passed  through  so  many 
needles,  by  means  of  which  two  portions  of  gut  could  be  made  to  anastomose.  Originally,  Senn's 
device  was  intended  merely  to  establish  lateral  interosculation  of  two  distant  portions  of  gut  in 
certain  cases,  as  for  example  in  intestinal  obstruction  dependent  on  cicatricial  or  neoplastic  char- 
acter, and  thus  save  time  by  eliminating  the  necessity  for  precedent  excision  and  subsequent  enter- 
orrhaphy.  The  places  for  the  establishment  of  the  new  communication  having  been  selected,  a 
transverse  incision  of  from  one  to  two  inches'  length  is  made  into  each  section  of  gut  (see  Fig. 
120  d).  a  bone  plate  is  slipped  into  one  of  these  newly-made  apertures,  and  is  attached  to  its 
edges  by  the  transfixion  of  the  entire  thickness  of  the  gut  with  the  four  needles  which  belong 

to  the  bone  plate.  After  the  second 
aperture  is  provided  for  in  a  similar 
manner,  the  corresponding  threads  are 
tied  firmly.  Thus  the  two  apertures 
are  brought  to  correspond  exactly,  and 
the  peritoneal  surfaces  in  the  vicinity 
of  the  openings  are  retained  in  close 
and  secure  contact.  For  the  sake  of 
greater  security,  a  few  Lembert  stitch- 
es are  applied  outside  of  the  line  of 
contact.  Senn  also  advises  that  the 
surfaces  to  be  brought  into  apposition 
should  be  scratched  with  the  point  of 
the  needle,  to  hasten  speedy  agglutina- 
tion. 

Care  must  be  taken  that  the  newly- 
united  sections  of  intestine  are  joined 
together  so  as  to  permit  the  unimpeded 
progress  of  intestinal  contents  in  a 
homonymous  direction.  (This  was  not 
observed  in  the  illustration  (Fig.  120  d), 
taken  from  Abbe,  where  the  nature  of 
the  anastomosis  would  compel  the  in- 
testinal current  to  change  its  direction 
to  the  extent  of  180  .)  As  far  as  ex- 
penditure of  time  is  concerned,  the 
rapidity  of  this  simple  process  places 
it  far  above  the  Lembert-Czerny  sut- 
ures. 

Abbe  has  still  further  improved  the 
method   by  substituting  easily  procur- 
able catgut  rings  for  Senn's  bone  plates,*  the  preparation  of  which  is  somewliat  circumstan- 
tial (see  Fig.  120  e). 

Strangely,  the  development  of  the  new  operation  was  brought  to  its  logical  culmination  by  a 
homoeopathic  practitioner  of  Philadelphia, f  who,  after  excising  twelve  inches  of  intestine  for 
gangrene,  successfully  united  the  gut,  end  to  end,  by  means  of  rings  made  of  ordmary  rubber 
drainage  tubing.  Though  found  in  curious  company,  the  paper  containing  the  report  of  the 
case  bears  internal  evidence  of  credibilitv  and  knowledge. 


Fig.  120  e. — Apposition  ring  of  catgut.     (Abbe.) 


*  Robert   Abbe,  Complete  Obstruction  of  the  Colon  successfully  relieved,  etc. 
Medical  Journal,"  March  23,  1889. 

■j-  Van  Lennep,  "  Ilahnemannian  Monthly,"  vol.  xsiv,  No.  10,  October,  1889. 


"  New  York 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.        163 


XII.    HYDROCELE,   VARICOCELE,   AND   CASTRATION. 

1.  Hydrops  of  the  tunica  vaginalis  of  the  testis  is  either  an  essential 
disorder  per  se,  or  is  symptomatic  of  some  acute  or  chronic  affection  of  the 
testicle.  If  it  be  produced  by  acute  epididymitis  and  orchitis,  it  is  transient ; 
but  if  its  cause  is  tuberculosis,  or  cancer,  or  syphilis  of  the  testicle,  it 
assumes  the  character  of  a  chronic  complaint.  For  the  sake  of  a  correct 
prognosis  the  recognition  of  secondary  hydrocele  is  important,  as  it  is  im- 
probable that,  brought  on  by  these  affections  of  the  testicle,  hydrocele  can 
be  cured  by  either  tapping  and  injection  or  the  radical  oiDcration. 

If  the  hydrocele  is  very  tense,  preliminary  tapping  is  advisable,  in  order 
to  afford  an  opportunity  for  estimating  the  condition  of  the  testicle. 
Should  this  be  found  rugged,  swollen,  and  hard,  it  is  very  doubtful  that 
measures  directed  to  the  cure  of  the  effusion  will  be  successful,  unless  the 
condition  of  the  testicle  be  improved  by  appropriate  treatment.  Gummy 
swellings  will  usually  disappear  under  antisyphilitic  medication,  and  with 
them  the  hydrocele.  Tuberculosis  and  cancel^,  on  the  other  hand,  will 
require  castration. 

The  cure  of  simjjie  hydrocele  hy  tapping  and  subsequent  i7ijection  with 
tincture  of  iodine  or  pure  carbolic  acid  is  safe,  and  is  generally  followed  by 
cure.  The  only  caution  to  be  taken  is  a  proper  disinfection  of  the  trocar  or 
cannula  to  be  used,  by  either  boiling  in  carbolized  lotion  (five  per  cent),  or 
by  heating  the  instrument  in  an  alcohol-flame.  Care  must  also  be  exercised 
not  to  leave  behind  in  the  sac  too  large  a  quantity  of  the  tincture  of  iodine, 
as  there  is  on  record  a  case  of  acute  iodine-poisoning  brought  on  by  that 
circumstance. 

Volkma7in''s  radical  operation  is  also  safe,  and  offers  the  best  chances 
of  a  permanent  cure  ;  but  it  necessitates  longer  confinenent  of  the  patient 
than  the  preceding  method.  The  author  has  performed  this  operation  suc- 
cessfully forty-eight  times  on  thirty-one  patients,  and  no  serious  disturbance 
was  ever  observed  during  the  course  of  healing.  In  each 
case  cure  was  complete  in  from  two  to  three  weeks,  and 
was  permanent.  Lately  the  operation  was  done  with 
the  aid  of  local  ansesthesia  by  cocaine. 

The  procedure  is  as  follows  :  The  penis  and  scrotum 
are  shaved,  scrubbed  off,  and  disinfected.  A  rubber  band 
or  drainage-tube  is  tied  about  the  root  of  the  penis  and 
scrotum,  and  about  twenty  minims  of  a  five-per-cent 
solution  of  cocaine  are  injected  along  the  prospective 
line  of  incision.  The  skin  and  dartos  are  incised  for 
about  two  inches,  and  the  exposed  tunica  is  opened.  A 
grooved  director  is  slipped  into  the  sac,  which  is  then 
slit  open,  this  incision  being  somewhat  shorter  than  the 
cutaneous  one.  The  sac  is  mopped  out  with  a  sponge 
dipped  in  a  five-per-cent  solution  of  carbolic  acid.  After  this  the  tunica  is 
stitched  to  the  skin  by  a  continuous  suture  of  fine  catgut.     A  small  drain- 

23 


Fig.  121.— Diasram 
illustrating  Volk- 
ruann's  operation 
for  hydrocele. 


164  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

age-tube  is  inserted  and  secured  from  slipping  in  by  transfixion  witli  a 
safety-pin.  The  constricting  rubber  band  is  removed,  and  the  scrotum  is 
held  compressed  between  two  sponges  for  a  few  minutes  to  stanch  any  pos- 
sible hremorrhage.  A  small  strip  of  disinfected  rubber  tissue  is  laid  on  the 
wound,  which  is  enveloped,  together  with  the  entire  scrotum,  in  a  dry  dress- 
ing, held  down  by  a  roller  bandage  applied  in  the  manner  described  in  the 
paragraph  on  herniotomy.  (Fig.  121.)  The  dressings  are  changed  on  the 
third  day  after  the  operation.  On  the  second  day  the  movement  of  the 
bowels  is  attended  to  by  enema  or  laxative.  On  changing  the  dressings  the 
patient,  can  be  permitted  to  get  up  and  to  exercise  moderately.  The  wound 
is  dressed  with  a  strip  of  iodoformed  gauze  until  it  is  healed. 

2.  Varicocele  of  a  moderate  degree  is  best  treated  according  to  Keyes's 
plan,  which  consists  of  subcutaneous  ligature  of  the  distended  veins  with 
catgut.  The  scrotum  being  cocainized,  the  cord  is  separated  from  the  vari- 
cose veins,  and  is  held  in  the  grasp  of  the  thumb  aud  index-tinger  of  the  left 
hand,  the  patient  standing  during  the  procedure.  A  straight  Peaslee's 
needle,  armed  with  a  loop  of  silk,  is  thrust  through  the  scrotum  from  in 
front  until  its  eye  appears  behind  the  scrotum.  The  left  hand  releasing  its 
grasp  is  used  for  placing  the  ends  of  a  medium-sized  thread  of  catgut  into 
the  loop  of  silk,  which  is  then  pulled  through  forward  and  out  of  the  an- 
terior puncture-hole,  and  the  catgut  is  released  from  the  silken  loop.  Now 
the  left  hand  grasps  again  the  scrotum,  and  the  needle  is  reinserted  exactly 
into  the  anterior  puncture-hole,  and  carried  around  the  varices  externally 
to  them,  and  close  to  the  scrotal  integument  backward,  until  it  emerges 
precisely  from  the  posterior  puncture.  The  other  end  of  the  catgut  thread 
is  then  taken  up  by  the  loop  of  silk,  and  is  brought  out  through  the  anterior- 
aperture  by  withdrawing  the  needle.  Both  ends  of  the  ligature  are  now 
seen  emerging  from  the  anterior  puncture-hole.  They  are  tightly  knotted, 
cut  off  short,  and  disappear  in  the  scrotum  as  soon  as  released.  A  slight 
amount  of  hard  swelling  will  appear  around  the  place  of  ligature  the  next 
day,  but  this  will  not  prevent  the  patient  from  attending  to  his  vocation. 

The  author  has  employed  this  method  with  the  best  success  in  ten  cases. 

Extensive  varicocele  can  be  cured  only  by  free  exposure,  double  ligature, 
and  excision  of  the  dilated  veins.  Under  aseptic  precautions  this  measure 
is  free  from  danger. 

Case. — E.  Luhiiing,  baker,  aged  twenty-one.  Large  varicocele  of  the  left  side,  ex- 
tending down  to  the  middle  of  the  inner  aspect  of  the  thigh.  April  25,  1882. — At  the 
German  Hospital  the  scrotal  varices  were  exposed  by  incision,  and  a  large  plexus  was. 
separated  and  tied  above  and  below.  The  intervening  veins  were  exsected.  Another 
incision  of  eight  inches  in  length  exposed  the  varicose  veins  extending  down  the  thigh, 
and  they  were  also  exsected  after  being  secured  by  double  ligature.  A  rather  wide  strip 
of  attenuated  skin  had  to  be  removed  along  with  the  veins,  preventing  entire  closure 
of  the  femoral  wound  by  suture.  Uninterrupted  cure  of  the  scrotal  wound  by  primary 
union  of  the  femoral  one  by  granulation.     June  22d. — Patient  was  discharged  cured. 

Four  more  somewhat  less  extensive  cases  were  treated  in  a  similar  man- 
ner, and  all  healed  by  the  first  intention. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC   METHOD.        165 

Care  must  be  taken  not  to  remove  all  the  veins  of  the  pampiniform 
plexus.  In  the  author's  sixth  case  necrosis  of  the  testicle  was  caused  by  too 
extensive  excision  of  the  dilated  veins. 

Case. — Joseph  Stern,  baker,  aged  twenty-two.  Extensive  varicocele  of  the  left 
side.  March  17,  1886. — Excision  of  varices  at  the  German  Hospital.  March.  27th.^ 
Necrosis  of  testicle  was  noted.  A  few  of  the  stitches  had  given  way,  and  the  yellow- 
ish, discolored  testis  was  distinctly  visible.  April  8th. — The  testicle  came  away  with 
very  moderate  sero-purulent  secretion.     April  26th. — Patient  was  discharged  cured. 

3.  Castration  is  indicated  by  neoplasms,  tuberculosis,  or  syphilis  of  the 
testicle,  in  the  latter  case,  however,  only  when  the  disease  is  not  amenable 
to  systemic  treatment,  and  is  a  source  of  much  suffering. 

The  author's  procedure  for  castration  is  as  follows  :  The  patient's  geni- 
tal region  is  shaved,  scrubbed  with  soap  and  hot  water,  and  disinfected  with 
corrosive-sublimate  lotion,  or,  if  any  open  ulcer  or  fistula  be  present,  these 
are  finally  syringed  or  touched  uj)  with  an  eight-jDer-cent  solution  of  chloride 
of  zinc.  First,  the  seminal  cord  is  exposed  well  above  the  diseased  testicle, 
and,  being  separated,  is  taken  up  by  the  index  of  the  left  hand.  The  ves- 
sels composing  it  are  successively  grasped  by  separate  artery-forceps,  while 
the  vas  deferens  remains  intact.  As  soon  as  all  the  vessels  are  thus  secured, 
they  are  nij^ped  off  one  after  the  other  with  the  scissors  in  front  of  the 
artery-forceps,  and  are  at  once  tied.  The  vas  deferens  is  cut  through. 
Before  being  released,  the  mesial  end  of  the  severed  cord  is  somewhat  relaxed 
and  carefully  inspected,  to  see  whether  all  bleeding  be  stanched  or  not. 

By  making  the  division  of  the  cord  the  first  step  of  the  operation,  the 
subsequent  parts  of  the  procedure  are  made  decidedly  less  bloody.  Dissec- 
tion of  the  testicle  jsroper  is  much  easier  and  more  rapid  than  if  the  reverse 
order  is  observed,  and  the  stump  of  the  cord  serving  as  a  convenient  handle, 
contact  of  the  surgeon's  fingers  with  ulcerating  surfaces  or  fistulte  can 
altogether  be  avoided.  A  few  more  ligatures  will  be  generally  needed  along 
the  bottom  of  the  scrotum. 

A  drainage-tube  is  inserted,  extending  from  the  inguinal  ring  down  to 
the  lower  angle  of  the  cutaneous  incision,  and  then  the  wound  is  united  by 
interrupted  catgut  sutures,  the  edges  of  the  cut  being  held  pinched  up  by 
the  fingers  in  passing  the  stitches.  A  dressing  similar  to  that  used  after 
herniotomy  is  applied  and  left  on  generally  for  three  or  four  days.  The 
tube  is  removed  with  the  first  dressing.  Tying  of  the  cord  in  mass  saves 
a  little  time  in  operating,  but  the  stump  generally  necroses,  and  cure  is 
very  much  delayed  by  the  slow  j^rocess  of  its  detachment. 

Castration  was  performed  by  the  author  twenty-nine  times  ;  in  twenty- 
four  cases  for  tuberculosis.  One  of  these  cases  died  of  crouj)ous  pneumonia, 
probably  induced  by  ether  anaesthesia. 

Case. — Moses  H.,  merchant,  aged  sixty.  January  2^,  1887. — Castration  for  tubercu- 
losis of  right  testicle  at  Mount  Sinai  Hospital  under  ether.  The  operation  did  not  pre- 
sent anything  unusual,  and  the  patient  did  well  after  it  until  two  clock  on  the  after- 
noon of  January  26th,  when  suddenly  high  fever  with  dyspnoea  appeared,  and  developed 
into  coma  within  a  few  hours.     At  6  p.  m.  the  thermometer  indicated  106'7°  Eahr.  in 


lOG  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

the  rectuin  ;  at  9.55  p.  m.  tlie  patient  died.  Dullness  at  the  base  of  the  right  lung^ 
made  out  a  few  hours  before  death,  corresponded  to  an  area  of  fresh  lobar  pneumonia 
found  at  the  autopsy.     The  wound,  peritoneal  cavity,  and  kidneys  were  normal. 

Twent3'-tliree  cases  castrated  for  tuberculosis  all  recovered. 

In  one  case  castration  was  done  for  syphilitic  gumma  of  the  left  testicle 
of  five  years'  standing,  which  had  remained  uninfluenced  by  various  kinds 
of  constitutional  treatment. 

Case. — John  "W.  G.,  brewer,  aged  thirty-eight.  Large  hydrocele  caused  by  chronic 
specific  disease  of  the  testicle.  March  4^  1887. — The  hydrocele  was  incised,  and  the 
testicle  was  found  very  much  enlarged ;  the  rugged  and  hard  epididymis  was  occupied 
by  a  solid  fibrous  mass  extending  well  into  the  glandular  tissue  of  the  testicle.  Cas- 
tration was  at  once  done.  March  15th. — Patient  discharged  nearly  cured,  the  place  of 
exit  for  the  drainage-tube  presenting  a  small  spot  of  granulations. 

In  two  cases  ablation  of  the  testicle  had  to  be  done  for  malignant  neo- 
plasm.    They  recovered. 

Case  I. — Jacob  Praeger,  tailor,  aged  seventy-two.  Very  large  giant-cell  sarcoma 
of  right  testis.  Decemier  4,  1870. — Castration.  Preparation  of  the  bowels  by  laxatives, 
was  insufficient,  and  on  the  third  day  after  the  operation  violent  colic  developed,  which 
could  not  be  controlled  by  opiates.  In  the  night  a  large  stool  escaped  into  the  bed, 
the  dressings  and  the  wound  were  soiled,  and  in  a  few  hours  fever  set  in.  The  wound 
was  injected  with  an  eight-per-cent  solution  of  chloride  of  zinc,  which  checked  the 
fever.  Much  sloughing  tissue  came  away,  but  patient  recovered,  and  was  discharged 
cured  about  five  weeks  after  the  operation. 

The  author's  experience  in  this  case  taught  him  the  valuable  lesson  of 
neve?'  trusting  the  patients'  statement  regarding  the  action  of  their  hoivels, 
and  never  leaving  the  manner  of  preparation  of  the  intestine  to  their  judg- 
ment. In  this  case  the  patient  assured  the  author  that  citrate  of  magnesia 
acted  on  him  like  a  charm.  Citrate  of  magnesia  was  taken,  with  the  result 
reported  above.  Had  a  good  dose  of  oil  or  calomel  raked  out  the  flaccid 
and  coprostatic  gut  of  tlie  old  man  before  the  operation,  his  life  would  not 
have  been  endangered  by  subsequent  fecal  infection  of  the  wound. 

Case  II. — Siegmund  Hertz,  clerk,  aged  thirty-two.  August  2J!f,  i555.— Castratiou 
of  right  testicle  for  myxosarcoma  at  Mount  Sinai  Hospital.  Primary  union.  Septem- 
her  15th. — Patient  discharged  cured. 

Tiuice  castration  was  done  for  spontaneous  gangrene  of  the  testicle. 
Both  cases  recovered.  The  record  of  one  was  lost ;  that  of  the  other  is  as 
follows  : 

Case. — George  Otto,  butcher,  aged  thirty-nine,  admitted,  February  2,  1880,  to 
German  Hospital  with  an  enormous  emphysematous  swelling  of  the  left  testicle.  The 
organ  had  nearly  the  size  of  a  man's  head,  was  dusky  red  and  hot,  showed  crepitus, 
and  gave  tympanitic  percussion-sound.  The  patient,  a  powerfully  built  man,  showed 
symptoms  of  most  acute  septic  intoxication.  He  stated,  on  being  shaken  out  of  his 
stupor,  that  the  swelling  had  come  on  three  days  ago  suddenly  with  much  pain  after 
a  probatory  puncture.  Immediate  ablation  of  the  organ  was  done.  The  skin  was  pre- 
served, and  the  very  large  wound  cavity  was  filled  with  a  packing  of  carbolized  gauze. 
An  almost  immediate  improvement  of  the  patient's  general  condition  followed.     The 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD. 


167 


wound  healed  rather  rapidly  by  granulation.  February  S6th. — Patient  was  discharged 
cured.  Examination  of  the  specimen  showed  bloody  infarction  of  the  testis  and  epi- 
didymis, with  far-gone  disintegration  and  softening  of  the  tissues.  The  tunica  and 
subcutaneous  connective  tissue  were  in  a  state  of  emphysematous  gangrene. 


Xm.     ASEPTIC    OPERATIONS    ON    THE    RECTUM. 

1.  General  Observations. — The  aseptic  performance  of  rectal  operations 
done  for  hfemorrhoidal  or  other  tumors  requires  a  careful  preparation  of 
the  gut.     It  consists,  first,  of  the 
administration    of  a  cathartic  like 


Fig.  122. — Lateral  view  of  patient  in  Bozeman's  position. 


castor-oil  or  calomel  several  days 
in   elderly  subjects  a 
week   before   the   op- 
eration,   followed    up 
by  the    daily  exhibi- 
tion of  a  saline  laxa- 
tive, to  be  given  on  an 
empty  stomach.    Four 
hours  before  the  time  of  the 
operation  a  large  enema  of 
soap-water    is    administered, 
and,  as  soon  as  it  has  acted, 

a  full  dose  of  opium  is  given  by  mouth,  or  is  introduced  into  the  rectum 
in  the  shape  of  a  suppository. 

When  the  ansesthetized  patient  is  laid  on  the  operating-table,  a  good- 
sized  sponge  attached  to  a  stout  silken  thread  is 
thrust  well  up  the  rectum,  and,  the  sphincter 
being  thoroughly  stretched  by  manual  force,  the 
anus  and  rectal  pouch  are  flushed  with  a  stream 
of  corrosive-sublimate  lotion  (1  :  1,000)  thrown 
from  an  irrigator. 

During  the  progress  of  the  operation  irrigation 
has  to  be'  kept  up  con- 
stantly at  short  inter- 
vals. When  the  perito- 
neeum  is  approached, 
or  has  to  be  invaded  by 
the  surgeon, Thiersch's 
solution  is  substituted 
for  the  mercuric  lotion 
as  an  irrigating  fluid. 
3.  Heemorrhoids. — 
A  varicose  condition 
of  the  hfemorrhoidal 
veins  of  recent  origin. 

Fig.  12-3. — Posterior  view  of  patient  in  Bozeman's  position.  caUSCd    by    SOmC    dis- 


168  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

turbance  of  the  portal  circulation,  is  often  amenable  to  general  treatment 
by  fnlfllliug  the  causal  indication.  Removing  a  fecal  retention,  or  regu- 
lating the  portal  circulation  with  a  dose  of  calomel,  followed  up  by  a  course 
of  Carlsbad  salts,  will  often  do  away  with  the  hsemorrhoids  caused  by  these 
conditions.  Or  regulation  of  the  heart's  action  by  digitalis  in  valvular 
lesions  will  be  followed  by  marked  improvement.  When  the  haemorrhoidal 
nodes  are  in  a  state  of  acute  phlebitis,  marked  by  painful  hot  swelling  and 
fever,  topical  applications  of  cold  in  the  shape  of  enemata  of  ice-water  or 
iced  compresses  will  give  much  relief. 

Aggravated  cases,  however,  especially  when  there  is  a  state  of  prolapse 
of  the  mucous  membrane  of  the  anus,  can  be  cured  only  by  operative 
measures. 

Of  all  operations  for  the  cure  of  bgemorrhoids,  that  by  ligature  com- 
mends itself  as  one  of  the  simplest.  This  statement  is  based  on  an  experi- 
ence gathered  from  several  hundred  cases  operated  by  the  author  according 
to  various  methods. 

The  manner  of  procedure  is  as  follows  :  The  anaesthetized  patient  is 
brought  either  in  the  lithotomy  position,  with  a  hard  cushion  under  his 
buttocks,  or  he  is  arranged  in  Bozeman's  manner  for  the  operation  of  vesico- 
vaginal fistula  (Figs.  122  and  123).  This  latter  position  is  especially  use- 
ful where  the  assistance  needed  for  holding  the  patient  in  the  lithotomy 
position  can  not  be  procured.  In  both  cases  the  feet  and  legs  of  the  patient 
should  be  protected  from  exposure  by  a  wrapping  of  rubber  sheets.  These 
should  be  covered  over  with  clean  towels  wrung  out  of  mercuric  lotion  for 
the  protection  of  the  assistants'  hands  from  contamination. 

Selecting  the  lithotomy  position,  the  patient's  palms  should  be  brought 
in  contact  with  his  soles,  and  this  relation  should  be  secured  by  tight  band- 
aging. The  operator,  well  j^rotected  by  a  rubber  apron,  takes  a  seat  in  front 
of  the  patient,  and  jiroceeds  to  vigorously  stretch  the  sphincter  ani  muscle 
with  his  thumbs  inserted  in  the  anus.  As  soon  as  the  sphincter  is  paralyzed 
by  stretching,  the  haemorrhoidal  nodes,  external  and  internal,  will  spontane- 
ously protrude.  A  sponge  secured  with  a  thread  of  silk  is  thrust  into  the 
rectum,  and  the  field  of  operation  is  cleansed  by  irrigation.  The  lowest 
node  is  grasped  with  an  artery  forceps,  and,  being  well  drawn  out,  is  cir- 
cumscribed by  a  shallow  incision  made  with  a  pair  of  curved  scissors.  A 
curved  needle  is  taken,  armed  with  a  double  thread  of  stout  disinfected  silk, 
and  with  it  the  base  of  the  tumor  is  transfixed  from  without  inward.  The 
silk  is  cut  near  the  needle,  and,  the  threads  being  separated,  the  base  of  the 
node  is  tied  in  two  portions.  The  node  is  cut  off  below  the  ligatures,  and 
then  the  remaining  nodes  are  attended  to  in  a  similar  manner.  When  the 
operation  is  finished,  some  iodoform  powder  is  rubbed  into  the  nodal  stumps, 
and,  after  a  final  irrigation,  the  sponge  is  withdrawn  from  the  rectum, 
which  is  mopped  out  dry  with  another  sponge  attached  to  a  long  stick  or 
sponge-holder.     (Fig.  124,  a  and  c.) 

A  hollow  tampon  is  next  prepared  by  wrapping  a  few  layers  of  iodoform- 
ized  gauze  around  a  piece  of  stout  rubber  tubing  three  inches  long.     This 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.        169 


is  introduced  into  the  rectum  well  beyond  the  sphincter,  and  its  protruding 
end  is  transfixed  with  a  large-sized  safety-pin.     (Fig.  125.) 

The  object  of  this  tampon  is  twofold.     Its  main  object  is  to  facilitate 

the  escape  of  flatus,  a  circumstance  highly 
appreciated  by  elderly  flatulent  indiyiduals. 
Another  purpose  is  the  prevention  of  oozing 
•om  the  stitch-holes. 


The  anal  region  is  thickly  anointed  with 
vaseline,  and,  the 
safety-pin  being  un- 
der-padded with  a 
few  strips  of  iodo- 
formized  gauze,  a 
large  pad  of  corros- 
ive-sublimate gauze 
is  held  down  to  the 
anus  by  a  T-band- 
age.     (Fig.  126.) 

Forty-eight  hours 
after  the  operation 
four  ounces  of  sweet 
oil   are    injected    into 
the    rectum    through 
the  rubber  tube,  which 
can    be   withdrawn    a 
short  while  after  with 
very  little  pain  to  the 
patient.     A  large  ene- 
ma of  soap-water  is  at 
once  administered,  and 
generally  is  followed  by  an  evacuation  of  the 
bowels.    After  the  stool  another  small  enema 
is  given  to  cleanse  the  heemorrhoidal  stumps 
of  adherent  faeces.     The  anus  is  dressed  with 
a  strip  of  iodoformized  gauze  and  a  pad  as 
before. 

The  next  morning  a  dose  of  salts  is  given,  and,  stool  following,  the  rec- 
tum is  again  Avashed  out  afterward.  This  practice  may  have  to  be  repeated 
once  or  twice  within  the  next  few  days. 

The  patient  may  be  permitted  to  get  up  about  ten  days  after  the 
operation,  but  must  remain  at  home  till  after  the  detachment  of  the 
ligatures. 

Cauterization  toith  fuming  nitric  acid  was  formerly  also  much  employed 
by  the  author  ;  but  in  one  case  almost  fatal  haemorrhage  occurred  from  a 
small  artery  just  within  the  sphincter  on  the  detachment  of  the  eschar. 
Since  then  the  author  has  abandoned  this  practice. 


170 


EULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


fiG.  125. — Tampon-tube. 


Case. — Mr.  M.  P.,  gilder,  aged  thirty-one.  Fehru- 
nry  2^,  1882. —  Cauterization  of  external  and  internal 
haemorrhoids  with  nitric  acid.  March  10th. — At  2  a.  m. 
the  author  was  hastily  summoned  to  the  bedside  of 
the  patient,  and  found  him  in  a  collapsed  condition. 
He  reported  that  shortly  after  supper  he  felt  a  desire 
to  stool,  and  had  a  copious  evacuation.  Evacuations 
followed  since  then  about  every  hour,  but,  the  closet 
being  dark,  he  could  not  say  whether  the  stools  were 
bloody.  At  1  a.  m.,  on  coming  back  to  bed  from  the 
water-closet,  the  patient  fainted.  Being  brought  to 
bed,  another  stool  followed,  consisting  of  a  large  clot 
and  some  liquid  blood.  The  patient  was  at  once  anaes- 
thetized, and,  a  speculum  being  inserted,  a  rather  large- 
sized  artery  was  seen  spurting  from  where  an  eschar 
had  been  detached  just  inside  of  the  sphincter.  The 
vessel  was  seized  and  tied,  and  the  patient  made  a  good 
recovery. 

Langenbeck'' s  clamp  and  actual  cautery  meth- 
od is  very  good  and  safe,  its  only  drawback  be- 
ing the  necessity  for  a  cautery  apparatus.  Care 
must  be  taken  not  to  grasp  with  the  clamp  the 
nodes  too  near  their  base,  as  the  resulting  eschar  is  apt  to  be  very  large, 
and  anal  stricture  may  follow.  The  hollow  tampon  is  very  useful  in  this 
method  also,  and  its  use  can  be  warmly  recommended  (Fig.  124,  b). 

Whitehead's  Method  hy  Excision  and  Suture. — Whenever  an  aggravated 

case  of  haemorrhoids 
is  found  associated 
with  more  or  less 
considerable  pro- 
lapse of  the  rectal 
mucous  membrane, 
excision  of  the  irre- 
ducible nodes  with 
subsequent  suture 
of  the  circular 
wound  is  advisable. 
The  author  has  test- 
ed the  value  of  this 
operation  in  forty- 
seven  unselected 
cases.  In  the  hands 
of  an  expert  sur- 
geon the  operation 
gives  excellent  re- 
sults, and  can  be  done  raj^idly  and  with  moderate  loss  of  blood.  If  the 
wound  heals  by  the  first  intention,  the  time  required  for  a  cure  is  shorter 


Fig.  126. — T-bandage  in  situ. 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.        171 

than  with  any  other  effective  method,  and  the  course  of  the  after-treatment 
is  remarkably  free  from  nntoward  complications.  The  drawbacks  of  this 
process  are,  that  few  general  practitioners  have  the  requisite  expertness  to 
perform  it  well  and  rapidly.  Failure  of  primary  union  in  the  entire  cir- 
cumference of  the  gut  entails  unavoidable  stricture,  requiring  methodical 
dilatation,  or  even  renewed  excision  and  suture.  The  modus  procedendi  is 
as  follows  : 

After  stretching  the  sphincter,  a  sponge  is  placed  well  up  in  the  rectal 
pouch,  and  the  field  of  operation  is  thoroughly  disinfected.  A  circular  in- 
cision, including  the  entire  ring  of  haemorrhoids,  is  carried  around  the  anal 
aperture,  close  to  the  mucous  membrane.  About  one  half  of  the  muco- 
cutaneous margin  should  be  preserved  intact.  Fleshy  tabs  belonging  to  the 
outer  skin  should  not  be  included  in  this  circle,  and  no  skin  should  ever 
be  removed,  as  this  is  sure  to  result  in  ectopia  of  the  normal  mucous  mem- 
brane. The  incision  is  deepened  until  the  fibers  of  the  sphincter  are  ex- 
posed, when  the  mucous  membrane  containing  the  turgid  haemorrhoids  can 
easily  be  stripjDed  up  all  around  from  the  underlying  tissues  to  a  line  about 
an  inch  beyond  the  nodosities.  Cut  vessels  are  at  once  deligated.  The 
detached  cylinder  is  longitudinally  divided  on  one  side.  From  the  end  of 
this  longitudinal  cut  a  circular  section  is  carried  through  the  detached  gut, 
severing  it  from  the  rectum.  This  circular  section  should  be  done  grada- 
tim — that  is,  after  cutting  ofE  an  inch  or  so,  the  mucous  membrane  should 
be  stitched  to  the  outer  skin  as  soon  as  it  is  divided,  and  so  on,  until  the 
entire  circumference  of  the  hsemorrhoidal  mass  is  cut  off  and  the  mar- 
gins stitched.  If  tension  is  great,  the  process  will  be  much  facilitated  by 
the  insertion  of  a  buried  catgut  stitch  carried  through  the  submucous 
layer  on  one,  and  through  the  subcutaneous  tissue  on  the  other  side.  This 
will  render  the  apposition  of  mucous  membrane  and  cutaneous  margin 
easy,  and  the  sutures  will  not  cut  through  prematurely.  From  ten  to  fif- 
teen stitches  will  be  needed  to  unite  the  cut  edges.  After  the  removal  of 
the  sponge  from  the  rectal  pouch,  a  tampon  tube  is  inserted  and  the  case  is 
treated  in  the  usual  fashion. 

To  secure  jserfect  asepsis,  the  wound  should  be  frequently  irrigated  dur- 
ing the  progress  of  the  operation,  but  especially  well  before  the  closure  of 
the  sutures.  The  patient's  bowels  are  to  be  moved  not  before  forty-eight 
and  not  later  than  sixty  hours  after  the  operation.  In  successful  cases  the 
cure  will  require  from  two  to  three  weeks. 

3.  Rectal  Tumors. — Since  the  publication  of  Volkmann's  remarkable 
results  achieved  by  extirpation  of  the  rectum  for  cancer,  the  operation, 
formerly  condemned,  has  met  with  frequent  imitation.  The  author's 
melancholy  record  of  six  deaths  out  of  nine  operations  has  nothing  to 
inspire  great  confidence.  It  must  be  said,  however,  that  most  of  these 
operations  were  performed  under  very  unfavorable  conditions.  All  the 
patients  presented  instances  of  very  extensive  involvement  of  the  gut, 
requiring  in  each  case  the  removal  of  more  than  three  inches — in  one  case, 
nine  inches — of   intestine.      Almost  all  of   them  were  jDerformed  during 

24 


172  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

the  first  years  of  the  author's  independent  surgical  activity,  when  his 
mastery  of  tlie  difficult  technique,  both  of  the  aseptics  and  hemostasis  of 
the  region  in  question,  was  imperfect.  Much  unnecessary  haemorrhage 
was  incurred,  and  several  of  the  most  important  cautelse  against  infec- 
tion remained  unemployed.  Accordingly,  two  patients  died  shortly  after 
the  operation,  of  collapse  due  to  acute  anaemia  :  two  died  of  purulent 
peritonitis,  caused  by  infection  of  the  incised  peritonaeum  ;  one  died  of 
sejjticfemia,  induced  by  the  presence  of  a  large  retroperitoneal  abscess,  ex- 
tending far  up  in  front  of  the  vertebral  column.  One  patient,  a  very 
fat,  flabby  woman,  died  of  lobar  pneumonia  at  a  time  when  the  wound  was 
nearly  healed. 

Three  cases  of  very  extensive  removal  of  the  rectum  made  a  remarkably 
short  and  easy  recovery. 

Case  I. — Ed.  Turner,  mechanic,  aged  twenty-nine.  Extensive  soft  adenoid  cancer 
of  the  rectum,  of  rapid  growth.  The  involved  part  of  the  gut  was  freely  movable, 
although  its  upper  limit  could  not  be  reached  by  the  tip  of  tlie  index-tinger.  Xovem- 
her  i^,  188Jf. — Extirpation  of  the  rectum  at  Mount  Sinai  Hospital.  As  the  growth 
did  not  extend  downward  to  within  an  inch  of  the  sphincter,  this  muscle  was  pre- 
served. The  coccyx  was  exposed  by  a  posterior  median  incision,  and  was  exsected. 
The  mucous  membrane  of  the  lower  end  of  the  gut  was  dissected  up  in  the  shape  of  a 
cylinder,  and  was  closed  by  a  bgature  to  prevent  tlie  escape  of  rectal  contents  during 
the  operation.  Every  vessel  was  immediately  secured  and  tied,  either  at  being  cut  or 
before  division,  if  it  could  be  previously  recognized.  The  levator  ani  muscle  was 
detached  by  dissection  from  the  intestine.  All  resisting  bands  of"  tissue,  mostly  con- 
taining vessels,  were  secured  by  double  mass  ligatures  before  being  divided.  Most  diffi- 
culty was  met  with  in  freeing  the  gut  from  its  attachments  to  the  deep  pelvic  fascia, 
but  by  dint  of  mass  ligatures  this  was  also  overcome.  As  soon  as  the  pelvic  fascia  was 
passed,  the  intestine  readily  yielded  to  traction,  and  was  withdrawn  until  the  upper 
bmit  of  the  tumor  was  distinctly  felt  through  the  walls  of  the  gut.  The  peritonjeum 
was  detached  anteriorly  by  blunt  separation,  but  it  had  to  be  incised  on  the  posterior 
aspect  of  the  rectum  to  permit  complete  removal  of  the  growth.  The  gut  was  grasped 
with  a  large  clamp-forceps  about  an  inch  above  the  tumor,  and  was  severed.  The 
patent  orifice  of  the  rectum  was  carefully  cleansed  and  disinfected,  and,  the  clamp 
being  removed,  a  number  of  vessels  of  the  rectal  wall  were  secured  and  tied.  During 
the  whole  operation  the  wound  was  almost  constantly  irrigated  with  corrosive-subli- 
mate lotion  (1  :  2,500).  The  peritoneal  incision  being  closed  by  catgut  suture,  the 
wound  was  loosely  packed  with  iodoformized  gauze  after  the  insertion  of  two  drain- 
age-tubes into  its  bottom,  and  the  gut  was  attached  to  the  skin  by  two  silk  sutures. 
The  ends  of  the  drainage-tubes  were  left  projecting  from  the  dressings,  and  the  wound 
was  flushed  through  them  at  regular  intervals  of  an  hour.  The  temperature  remained 
normal  except  on  the  sixtli  day,  when  it  rose  to  103°  Fabr.  The  jiatient  complained 
of  colicky  pains,  and  a  saline  purge  was  administered.  A  stool  following,  the  fever 
disappeared.  The  wound  was  carefully  cleansed  by  irrigation  after  each  stool,  and 
healed  in  spite  of  its  great  extent  in  six  weeks.  The  removed  portion  of  the  gut  meas- 
ured, when  laid  upon  the  table,  just  five  inches. 

The  resulting  incontinence  of  the  widely  patent  gut  was  remedied  by  a  procto- 
plasty performed  February  28.  1885,  at  the  German  Hospital.  The  divided  ends  of 
the  preserved  sphincter  muscle  were  dissected  out,  and  were  united  by  a  row  of  catgut 
stitches  placed  in  the  median  line.     In  April,  1890,  the  patient  was  free  from  relapse. 


SPECIAL  APPLICATION  OF  THE  ASEPTIC   METHOD.        I73 

Case  II. — Eugene  HafEner,  waiter,  aged  twenty-four.  Relapsing  cancer  of  rectum 
after  extirpation  done  by  Dr.  F.  Lange.  February  2Jf,  1887. — Extirpation  of  addi- 
tional two  inches  of  the  gut  at  the  German  Hospital.  Peritonseum  was  found  de- 
scended to  within  half  an  inch  from  the  skin.  It  had  to  be  freely  incised,  and  was 
subsequently  closed  by  fire  catgnt  sutures.  Uninterrupted  recovery.  April  2d,. — 
Patient  was  discharged  cured. 

In  the  third  case  Kraske's  procedure  was  employed.  It  consists  in  the 
preliminary  removal  of  the  coccyx  and  a  portion  of  the  lower  half  of  the 
sacrum,  whereby  the  remoYal  of  the  rectum  is  very  much  facilitated. 

Case  III. — Koppel  Barscheinik,  tailor,  aged  forty-six.  Circular  and  massive  can- 
cer of  anus  and  rectum,  extending  five  inches  beyond  the  anal  aperture.  General 
condition  fair.  March  1,  1889. — Excision  of  rectum  by  Kraske's  method  at  ATount  Sinai 
Hospital.  Coccyx  and  sacrum  were  exposed  by  a  median  incision.  The  former  being 
removed,  the  sacrum  was  denuded,  and  by  means  of  the  chisel  and  mallet  its  lower 
half  was  divided  in  the  median  line  up  to  the  height  of  the  third  sacral  foramen,  where 
its  left  lower  segment  was  entirely  severed  by  a  transverse  cut.  After  this  the  anal 
end  of  the  gut,  together  with  the  sphincter,  were  dissected  out  and  tied  off  in  mass  to 
prevent  the  escape  of  rectal  contents.  Thus  the  liberation  of  the  diseased  part  of  the 
rectum  became  a  remarkably  easy  task.  The  hfemorrhage  was  readily  controlled,  the 
gut  severed  an  inch  and  a  half  above  the  limits  of  the  disease,  the  opened  peritonajum 
closed  with  a  few  catgut  stitches,  and  the  stump  of  the  gut  loosely  sutured  to  the 
upper  angle  of  the  wound.  The  open  parts  of  the  wound  were  packed  with  iodoform 
gauze.  Duration  of  the  operation,  forty-five  minutes.  The  removed  portion  of  the 
rectum  measured  six  inches.  The  patient  rallied  well.  On  the  fifth  day  fever  was 
observed,  and  an  abscess,  located  between  the  rectal  stump  and  sacrum,  was  found  and 
opened,  after  which  the  temperature  fell  to  the  normal  standard.  By  July  2d  the 
wound  had  healed  and  about  three  inches  of  the  rectal  mucous  membrane  had  gradu- 
ally prolapsed.  The  gut  was  separated  from  its  attachments,  the  cicatrix  was  divided 
down  to  the  original  site  of  the  anus,  and  the  intestine  was  attached  to  its  original 
habitat.  A  triangular  segment  was  excised  ft-om  the  lower  end  of  the  intestine  to 
somewhat  narrow  its  aperture.  The  stitches  partially  gave  way,  and  a  third  smaller 
operation  had  to  be  done  September  30th,  to  secure  the  desired  result.  This  stretch- 
ing out  of  the  rectal  stump  did  away  with  the  tendency  to  prolapse  ;  the  patient's  solid 
fgeces  were  very  weU  retained  by  a  sort  of  sphincter  about  three  inches  above  the 
anal  opening.  His  general  condition  had  improved  remarkably,  and  he  is  now  (May, 
1890)  attending  to  his  business. 

The  main  source  of  infection  is  the  interior  of  the  gut.  To  exclnde 
this  danger,  the  lower  end  of  the  rectum  must  be  closed  by  a  circular 
ligature.     When  the  gnt  is  divided  above,  care  must  be  taken  to  prevent 

soiling  of  the  wound  by  escaping  intestinal  contents. 

XrV.    ASEPTICS    OF    THE    BLADDER. 

1.  Catheterism. — Infectious  processes  rarely  originate  in  the  bladder 
itself.  Their  most  common  way  of  entrance  is  by  the  urethra  from  with- 
out ;  next  to  this  come  the  modes  of  infection  from  within — that  is,  by 
descent  from  the  kidneys  or  by  extension  of  contiguous  septic  processes 
from  the  organs  located  in  the  vicinity  of  the  bladder,  as  for  instance  from 
peritoneal  or  retro-peritoneal  suppurations. 


174  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

As  before  indicated,  the  most  common  source  of  infection  of  the  bladder 
is  an  unclean  catheter.  The  ordinary  metliods  of  deansmg  metallic  catheters 
by  flushing  loith  hot  or  cold  loater,  and  siibseqiient  rubbing  off  with  a  clean 
toivel,  are  altogether  inadequate.  In  order  to  secure  their  absolute  cleanli- 
ness, the  same  processes  of  sterilization  must  be  employed  that  were  recom- 
mended for  cleansing  other  hollow  tubes — notably,  aspirating  needles  and 
trocars.  Boiling  for  an  hour  in  water,  or  jiassing  the  instrument  through 
an  alcohol  flame  until  all  organic  matter  contained  in  its  lumen  is  volatilized 
by  burning,  is  meant  thereby.  Only  after  smoke  and  steam  have  ceased  to 
escape  from  the  catheter  can  it  be  declared  to  be  surgically  clean. 

Before  use,  the  cleansed  catheter  should  be  placed  in  a  tray  or  flat  pan 
filled  with  tei)id  salt  water  (G  :  1,000,  or  one  heaped  teaspoonful  to  a  quart 
of  boiled  water) ;  the  surgeon's  hands  should  be  previously  well  washed  with 
soap  and  hot  water,  and  the  instrument  should  be  anointed  with  iodoform- 
ized  vaseline  of  the  strength  of  1 :  50  (fifteen  grains  to  two  ounces). 

Note. — The  ordinary  solutions  of  corrosive  sublimate  or  carbolic  acid  corrode  the  raucous 
membrane  of  the  urethra  and  bladder,  often  causing  intense  pain  and  reflex  symptoms.  The 
resulting  denudations  of  the  epithelial  layer  all  may  serve  as  poi-tals  of  subsequent  infection, 
manifesting  itself  in  the  form  of  urethral  fever,  urethritis,  cystitis,  and,  in  extreme  cases, 
metastatic  processes.  None  of  these  very  active  germicides  should  be  introduced  into  the 
healthy  urethra  or  bladder :  first,  because  they  are  unnecessary ;  and,  secondly,  because  they 
may  do  harm.  Simple  immersion  of  a  filthy  catheter  into  these  germicidal  lotions  will  not  dis. 
infect  it  sufficiently,  and,  if  some  of  the  strong  solution  be  carried  into  the  urinary  passages 
along  with  a  filthy  catheter,  the  chances  of  infection  will  only  be  increased  by  the  combination. 
Catheters  that  were  immersed  in  strong  disinfectant  solutions  should  be  freed  from  them  before 
being  used. 

In  ]iassing  the  instrument  into  the  bladder  for  exploration  or  evacuation, 
the  utmost  gentleness  should  be  exercised,  not  only  for  the  sake  of  the 
patient's  comfort,  but  also  because  it  is  of  importance  not  to  injure  the 
urethral  mucous  membrane.  Certain  parts  of  the  normal  male  urethra  will 
often  raise  obstacles  to  the  passage  of  the  instruments  which  should  never 
be  overcome  by  force,  but  only  by  patient  and  gentle  manipulation. 

The  first  obstacle  is  usually  met  at  the  suspensory  or  triangular  ligament. 
Holding  the  shank  of  the  catheter  parallel  with  the  abdominal  wall  while 
gently  extending  the  penis  uj^ward  in  the  same  direction,  thus  pulling  the 
latter  over  the  former  like  a  glove-finger  over  a  finger,  will  easily  guide  the 
beak  of  the  catheter  around  the  promontory  formed  by  the  inferior  margin 
of  the  symphysis  pubis. 

The  second  obstacle  will  be  occasionally  found  in  the  sinus  of  the 
bulbous  portion.  This  pitfall  must  be  avoided  by  exerting  digital  pressure 
upon  the  perinaeum,  and  indirectly  upon  the  beak  of  the  catheter  while 
gently  depressing  its  handle.  In  sensitive  urethrae,  the  compressor  urethrae, 
or  "  cut-off  "  muscle,  will  offer  by  reflex  contraction  considerable  resist- 
ance to  the  progress  of  the  operation,  especially  if  an  instrument  of  small 
caliber  be  employed.  It  is  injudicious  to  force  this  obstacle.  A  better 
plan  is  to  abide  the  moment  when  the  muscle  will  relax,  the  instrument 
being  held  against  the  resisting  band  by  gentle  pressure.    As  soon  as  relaxa- 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.        I75 

tion  begins,,  the  point  of  the   catheter   vrill   be  felt  slipping  through   the 
contracted  part  of  the  urethra. 

The  enlarged  prostate  is  the  last  and  most  difficult,  because  deepest, 
impediment  that  may  retard  the  operator.  A  long-beaked  instrument  will 
penetrate  to  the  bladder  easier  than  any  other  one.  The  handle  of  the 
catheter  must  be  deei^lj  dejiressed  between  the  thighs  of  the  patient,  and,  if 
this  be  insufficient,  the  tip  of  the  left  index-finger  introduced  in  the  rec- 
tum must  aid  the  entrance  of  the  beak  by  gentle  upward  pressure. 

Properly  performed  catlieterism  of  a  healthy  urethra  ajid  lladder  should 
not  hefoUoived  hy  hcemorrhage. 

Soft  catheters  made  of  gum  elastic  or  webbing  impregnated  with  resin- 
ous matter  are  never  safe  unless  their  history  is  known  to  the  operator. 
They  should  be  new,  or,  at  least,  such  should  neyer  be  employed  that  had 
been  previously  used  on  a  septic  case,  or  were  not  carefully  cleansed,  disin- 
fected, and  preserved  in  a  proper  manner  after  use. 

Soft  gttm-elastic  or  Xelaton  catheters  are  cheaj?,  and  need  not  be  pre- 
served after  liaving  been  used  in  a  septic  case.  Before  employing  a  soft  cath- 
eter, it  must  be  soaked  for  ten  minutes  in  hot  soap-water  and  flushed  out 
with  it ;  then  it  is  disinfected  with  a  strong  germicide  lotion,  preferably  corro- 
sive sublimate,  from  which  it  must  be  freed  again  by  another  flushing  with 
salt  water  before  it  is  anointed  with  iodoformized  vaseline  for  introduction. 
After  use,  the  catheter  should  be  again  flushed  otit  thoroughly  with  carbolic 
or  mercurial  lotion,  dried,  and  put  away  in  a  tight  box  or  wide-mouthed 
bottle.  If  needed  frequently,  the  catheter  should  be  kept  immersed  in  a 
two-per-cent  carbolic  lotion.  Before  use,  however,  the  adherent  carbolic 
lotion  must  be  always  removed  by  washing  in  salt  water.  The  author  saw 
a  considerable  number  of  cases  in  which  catlieterism  had  to  be  done  for  some 
time  after  rectal  operations,  and  in  which  troublesome  urethritis  devel- 
oped on  account  of  the  corrosion  caused  by  frequent  contact  of  the  urethral 
mucous  membrane  with  the  carbolic  acid  adherent  to  the  elastic  catheter. 

Searching  a  non-dilated  bladder  for  stone,  tumors,  or  foreign  bodies 
would  load  to  superficial  injury  of  the  mucous  membrane;  therefore,  dilata- 
tion, by  injecting  three  or  four  ounces  of  salt  water,  should  precede  every 
exploration.  After  completion  of  the  search,  clots  should  be  removed  by 
irrigation  with  the  saline  solution. 

These  remarks  refer  to  bladders  only  that  discharge  normal  urine. 

"Whenever  examination  of  the  urine  gives  evidence  of  a  catarrhal  or  se^)- 
tic  condition,  every  intravesical  manipulation  must  be  preceded  by  disinfec- 
tion of  the  bladder  by  Thiersch's  solution,  or  a  lotion  consisting  of  one  part 
of  permanganate  of  potash  to  five  thousand  parts  of  tej)id  water.  The  opera- 
tion should  be  completed  by  another  disinfecting  irrigation  of  the  organ. 

2.  Litholapaxy. — The  rapid  and  complete  evacuation  of  the  bladder  in 
one  session,  of  all  fragments  produced  by  crushing  concrements  with  a 
iithotrite,  forms  a  most  valuable  imj)rovement  of  the  technique  of  lithotripsy. 
Bigelow's  evacuator  enables  the  surgeon  to  free  the  bladder  at  once  of  all 
sharp-edged  fragments  of  stone.     This  circumstance  justifies  the  prolonga- 


176  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

tion  of  the  operation  to  an  extent  formerly  considered  unsafe,  as  subsequent 
irritation  caused  by  the  presence  of  sharp  fragments  is  thus  done  away  with. 

Before  introducing  the  lithotrite,  strictures  ought  to  be  cut  or  divulsed, 
and  tlie  bladder  ought  to  be  thoroughly  washed  out  with  tejiid  permanganate- 
of-potash  or  boro-salicylic  solution.  After  this  the  bladder  is  filled  with 
from  three  to  four  ounces  of  tepid  boro-salicylic  lotion,  and  the  lithotrite  is. 
introduced  well  anointed  with  iodoformized  vaseline.  The  penis  is  tightly 
deligated  with  a  piece  of  rubber  tubing,  and  the  stone,  being  grasped,  is 
crushed  first  into  a  number  of  larger,  and  subsequently  into  as  many  small 
fragments  as  possible.  The  crushing  instrument  is  removed  and  is  rejilaced 
by  the  evacuating  catheter,  wliich  is  connected  with  the  evacuating  bulb, 
that  was  previously  filled  with  boro-salicylic  lotion.  All  small  fragments 
are  next  sucked  out  of  the  bladder  by  the  apparatus.  Should  a  peculiar 
click  indicate  the  fact  that  one  or  more  fragments,  too  large  to  pass  the 
catheter,  are  still  remaining,  the  lithotrite  must  be  introduced  anew  to  com- 
plete their  reduction  to  a  proper  size,  after  which  complete  evacuation  Avill 
meet  no  difficulty.  The  bladder  is  washed  out  again  until  the  irrigating 
fluid  returns  free  from  blood,  and  the  patient  is  brought  to  bed. 

Small  stones,  especially  of  the  softer  varieties,  are  eminently  suited  for 
this  treatment,  which  has  the  great  advantage  of  a  short  convalescence  ; 
but  its  disadvantage  of  a  possible  relapse  from  failure  to  remove  all  frag- 
ments can  not  be  denied. 

Case  I. — M.  Witzkal,  peddler,  aged  tifty.  April  5,  I884,. — Litliolapaxy  at  the  Ger- 
man Hospital.  Uratic  stone  with  pliosphatic  shell  weighing  four  drachms  fifty-five 
grains.  Duration  of  operation  thirty-five  minutes.  Discharged  April  28th.  In  June, 
patient  was  readmitted  for  stone,  which  was  removed  by  Dr.  Adler  by  median  lithotomy. 

Case  II. — Mr.  E.  B.,  clerk,  aged  twenty-one,  renal  colic  followed  by  symptoms  of 
stone  in  the  bladder,  which  was  diagnosticated  by  sounding.  In  March,  1887,  lithot- 
rity  and  evacuation.  The  bladder  symptoms  continued  until  June,  when  Dr.  Schede, 
of  Hamburg,  removed  another  small  calculus. 

The  author  performed  litholapaxy  in  four  more  cases. 

Case  III. — Edward  Mink,  baker,  aged  twenty-one.  Jamiary  26,  1881. — Eapid 
lithotrity  for  a  phosphatic  calculus  weighing  two  hundred  and  fifty  grains.  March 
5th. — Patient  discharged  cured. 

Case  IV. — Henry  Bowitz,  agent,  aged  forty.  April  S4,  I884. — Litholapaxy  for 
uratic  calculus,  weighing  three  drachms  and  ten  grains,  at  Mount  Sinai  Hospital. 
May  10th. — Patient  discharged  cured. 

Case  V. — Francis  Johnson,  druggist,  aged  forty-seven.  Pliosphatic  calculus, 
ammoniacal  urine.  October  6,  1883. — Rapid  lithotrity  at  Mount  Sinai  Hospital. 
Weight  of  stone,  forty-seven  grains.  Duration,  fifty-five  minutes.  Discharged  cured, 
October  27th. 

Case  VI. — Philip  Prinz,  shoemaker,  aged  fifty-nine.  Rapid  lithotrity  for  small 
uratic  calculus,  done  January  25,  1887,  at  German  Hospital.  On  the  day  following 
the  operation  all  the  symptoms  of  stone  disappeared,  but  the  patient  sustained  a  burn 
of  the  legs  requiring  surgical  treatment.     This  delayed  his  discharge  until  March  17th. 

Intense  forms  of  cystitis  caused  by  the  presence  of  calculi  require  after 
lithotrity  continued  treatment  of  the  bladder  by  irrigation. 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.        177 

3.  Cystotomy. — In  perineal  as  well  as  in  suprapubic  cystotomy,  the  con- 
dition of  the  urine  should  serve  as  a  gaiicle  in  determining  whether  aseptic 
■or  antiseptic  measures  have  to  be  observed  during  the  operation.  When  the 
normal  condition  of  the  urine  indicates  that  the  vesical  mucous  membrane 
is  in  a  healthy  state,  strong  disinfecting  solutions  should  not  be  used  within 
the  bladder,  and  the  surgeon's  chief  attention  should  be  directed  to  the  care- 
ful cleansing  of  his  instruments,  in  order  to  avoid  the  introduction  of  filth 
into  the  bladder.  For  jDurposes  of  filling  and  cleansing,  a  saline  or 
'Thiersch's  solution  will  be  all  sufficient. 

In  cases  characterized  by  j)yuria,  with  or  without  ammoniacal  odor,  or 
with  outright  fetidity  of  the  urine,  disinfection  of  the  bladder  must  precede 
and  follow  each  operation. 

The  rules  of  ase23ticism  referring  to  the  treatment  of  the  external  wound 
must  also  be  scrupulously  observed.  During  the  after-treatment,  drainage 
•of  the  bladder  may  be  required,  especially  in  cases  where  a  septic  condition 
•of  the  organ  would  render  retention  of  fetid  urine  undesirable  or  risky.  A 
rather  stout  rubber  drainage-tube  inserted  in  the  bladder  will  answer  every 
practical  purpose. 

{a)  Peeineal  Sectio]^  : 

Case  I. — Fred.  Kurtz,  aged  fifty-five.  Phosphatic  stone,  ammoniacal  urine.  Feb- 
ruary 1,  1881. — Lateral  lithotomy  at  the  German  Hospital.  Weight  of  stone,  three 
drachms  and  forty  grains.  No  reaction  or  fever.  Continued  washings  of  bladder  with 
salicylic -acid  solutions.     April  10th. — Discharged  cured. 

Case  II. — Hugo  Liedtke,  aged  three  and  a  half.  Small  uratic  stone.  March  19, 
1881. — Lateral  lithotomy  with  the  assistance  of  the  family  attendant,  Dr.  Hassloch. 
Weight  of  stone,  eighteen  grains.     April  15th. — Discharged  cured. 


Pig.  127.— Arrangement  of  patient  for  perineal  cystotomy.     Feet  wrapped  up  in  disinfected  towels. 

(b)  SuPEAPUBic  Section. — Tumors,  a  very  large  prostate,  encysted  or 
very  large  stones,  oxalic  concrements,  or  rebellious  cystic  hasmorrhage  from 
dilated  veins  of  the  neck  of  the  bladder,  indicate  the  selection  of  the  high 


178 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


operation.  Petersen  and  Garson's  proposition  to  distend  both  bladder  and 
rectum  before  cutting,  marks  a  most  valuable  improvement  of  the  method, 
as  injury  to  the  anterior  reflection  of  the  peritoneeum  can  be  thus  avoided. 
A  soft  rubber  bag,  or  "  colpeurynter,"  similar  to  Barnes's  dilator,  is  intro- 
duced into  the  rectum,  and  is  filled  with  from  fifteen  to  eighteen  ounces  of 
water.  Escape  of  the  water  is  prevented  b}'  attaching  an  artery  forceps  to 
the  end  of  the  tube. 

Seven  or  eight  ounces  of  tepid  salt  water  or  boro-salicylic  lotion  are 
injected  into  the  bladder,  and  the  penis  is  tied  with  a  piece  of  rubber  tub- 
ing. The  patient's  shaved  suprapubic  region  is  carefully  disinfected,  and 
a  median  incision  is  made,  commencing  about  three  inches  above,  and  ex- 
tending to  the  symphysis.  The  recti  muscles  are  separated,  and  the  pre- 
vesical fat  is  incised.  Care  must  he  taken  not  to  injure  the  reflexion  of  the 
peritonmum,  lohich  may  be  looked  for  in  the  upper  angle  of  the  tuound.  In 
many  cases  the  peritoneum  will  not  come  in  view  at  all.  Should  distention 
of  the  rectum  and  bladder  not  suffice  to  push  up  and  out  of  the  way  the 
peritoneal  fold,  this  must  be  separated  from  the  bladder  by  blunt  dissection, 
to  be  done  preferably  by  the  tips  of  the  fingers.  Vessels  crossing  the  pre- 
vesical space  should  be  divided  between  double  ligatures. 

The  bladder  is  transfixed  on  each  side  of  the  median  line  with  curved 
needles,  carrying  fillets  of  silk.     The  vesical  incision  is  made  between  these 
hold-fasts  with  a  sharp-pointed  bistoury.     In  cases  of  doubt,  the  presenting 
organ  may  be  first  punctured  with  a  hypodermic  needle.     While  the  silken 
threads   keep  the  vesical  wound  patulous,  the  sur- 
geon's finger  explores  the  interior  of  the  bladder. 
Stones  are  then  extracted  with  forceps,  or  the  scoop, 
or  even  with  the  fingers,  tumors  are  inspected  and 
excised  under  the  guidance  of  the  eye,  and  bleeding 
varices  of  the  neck  of   the  bladder  are  grasped  and 
tied  off  or  touched  with  the  thermo-cautery. 

After  thorough  irrigation,  a  T-shaped  drainage- 
tube  (Fig.  128)  is  inserted  in  the  bladder,  and  the 
external  wound  is  loosely  packed  with  iodoformized 
gauze.  A  split  compress  of  the  same  material  is  ar- 
ranged about  the  projecting  end  of  the  tube,  and  is 
covered  with  a  number  of  compresses  consisting  of 
corrosive-sublimate  gauze.  The  skin  all  around  the 
wound  is  profusely  anointed  with  iodoformized  vase- 
line, and  the  dressings  are  held  down  by  a  few  turns 
of  a  roller-bandage.  The  patient  is  brought  to  bed, 
and  is  laid  on  his  side  upon  a  circular  air-cushion, 
his  back  being  supported  by  a  number  of  cushions 
held  up  by  the  backs  of  several  chairs,  or  by  boards 
stuck  into  the  side  of  the  bed.  As  the  lateral  position  has  to  be  maintained 
for  three  days  at  least,  sides  should  be  changed  every  two  or  three  hours. 
The  drainage-tube  projecting  from  the  dressings  is  connected  with  a  longer 


Fig.  128.— T-shaped  di-ain- 
age-tube  for  suprapubic 
cystotomy.  (Trende- 
lenburg. ) 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.         179 

tube,  that  is  led  into  a  urinal  placed  alongside  the  patient  in  or  out  of  bed. 
As  soon  as  the  urine  ceases  to  be  bloody,  and  its  reaction  becomes  acid,  the 
patient  may  be  allowed  to  assume  the  supine  posture.  The  drainage-tube 
can  be  removed  on  the  fifth  day,  when  the  wound  will  be  usually  found  in 
a  state  of  healthy  granulation.  The  packing  of  iodoformized  gauze  has 
to  be  continued  as  long  as  urine  escapes  through  the  wound.  As  soon  as 
urination  per  vias  naturales  is  re-established,  the  wound  should  be  dressed 
as  any  other  superficial  wound. 

Case  I. — Martin  G-yr,  laborer,  aged  fifty.  Large  oxalic  calculi  of  ten  years'  stand- 
ing, with  undilatable  bladder.  Wretched  general  condition.  A2}ril  12,  1886. — Supra- 
pubic lithotomy  at  the  German  Hospital  under  chloroform,  which  was  preferred  to 
ether  on  account  of  the  presence  of  casts  in  the  urine.  Two  immovable  stones  were 
found  occupying  the  contracted  bladder.  They  were  grasped,  freed  by  rotation,  and 
extracted  one  after  the  other.  They  showed  on  extraction  two  freshly  broken  sur- 
faces, corresponding  to  as  many  pedicle-like  projections,  branching  into  two  diverti- 
cles,  each  containing  a  separate  calculus.  One  of  these  calcuU  was  extracted,  the  other 
and  smaller  one  was  left  behind,  as  the  patient's  poor  condition  verging  on  collapse 
did  not  justify  continuation  of  the  operation.  The  patient  did  not  rally  from  the  col- 
lapse, and  died  three  hours  after  the  completion  of  the  lithotomy. 

The  suprapubic  incision  ga^e  free  access  to  the  bladder,  and  enabled  the 
author  to  conduct  the  search  and  extraction  of  the  calculi  under  the  guid- 
ance of  the  eye.  Eemoval  or  even  the  finding  of  the  encysted  calculi  would 
have  been  utterly  impossible  from  a  perineal  wound.  Weight  of  calculi,  one 
ounce,  five  drachms,  and  twenty  grains. 

Case  II. — Mr.  Adolph  "W".,  plumber,  aged  fifty-six.  Vesical  trouble  of  three  years' 
standing.  Urine  slightly  acid,  turbid,  containing  much  pus,  but  no  casts.  March  30, 
1887. — Exploration  of  the  very  irritable  bladder  with  the  stone-searcher  yielded  no 
positive  result.  April  18,  1887. — On  exploration  in  ether  anassthesia,  stone  was  found. 
A  Thompson  lithotrite  being  introduced,  a  large  stone  was  grasped,  and  on  rotation 
was  felt  to  grind  against  another  calculus.  Suprapubic  lithotomy.  Extraction  of  three 
stones,  each  weighing  about  forty-three  grammes,  their  aggregate  weight  being  four 
ounces  and  three  grains  Troy  weight.  April  20th. — Temperature,  100*5°  Fahr. ;  urine 
clear,  acid,  containing  no  blood  ;  its  daily  quantity  eighty  ounces.  April  23d. — Patient 
was  allowed  to  occupy  the  supine  position.  April  25th. — The  drainage-tube  was  with- 
drawn and  the  packing  removed.  A  soft  catheter  was  introduced  by  the  urethra,  and 
the  bladder  was  irrigated  through  it.  The  catheter  was  left  in  the  bladder ;  the  ex- 
ternal wound  was  repacked.  Temperature,  98'5°  Fahr.  Mat/  1st. — Thrombosis  of 
right  femoral  vein,  apparently  due  to  defective  circulation  caused  by  confinement. 
The  right  lower  extremity  enormously  increased  in  size.  Treatment :  Elevated  post- 
ure; later  on,  moist  packing,  and  elastic  compression  by  Martin's  bandage.  May  25th. 
— Lithotomy  wound  nearly  closed  ;  passed  some  water  through  urethra.  June  Ji.th. — 
Lithotomy  wound  closed ;  urination  normal.  Patient  up  and  about  most  of  the  time ; 
oedema  of  thigh  fast  diminishing.  June  20th. — Swelling  of  thigh  almost  gone ;  patient 
discharged  cured.  July  25th. — G-eneral  condition  excellent.  Patient  entirely  recov- 
ered. 

Case  III. — Mr.  Meyer  B.,  liveryman,  aged  thirty-nine.  Symptoms  of  very  acute 
cystic  catarrh  of  four  months'  duration,  causing  the  loss  of  fifty  pounds  of  flesh. 
Almost  constant  desire  of  and  very  painful  micturition,  the  acid   urine   containing 


180  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

blood,  pus,  some  mucus,  uric  acid,  and  oxalate-of-lime  crystals.  The  prostate  was 
very  painful  on  touch,  but  not  appreciably  enlarged.  The  patient  had  become  morphi- 
ophagous,  and  was  thoroughly  demoralized.  Stone  was  searched  for  unsuccessfully 
by  a  surgeon.  June  17,  1886. — Suprapubic  cystotomy  at  Mount  Sinai  Hospital.  No 
stone  was  found,  but  the  mucous  membrane  of  the  bladder  presented  a  most  marked 
state  of  hyperemia  and  thickening,  profusely  bleeding  at  the  slightest  touch.  The 
inflammation  was  most  pronounced  about  the  trigonum  and  the  neck  of  the  bladder, 
where  the  reddening  and  tendency  to  haemorrhage  were  most  intense.  Trendelen- 
burg's T-shaped  drainage-tube  was  inserted,  and  the  case  was  treated  in  the  lateral 
position.  The  cystic  irritation  ceased  at  once,  the  blood  and  pus  in  the  urine  dimin- 
ished, and  morphine  was  discontinued.  July  17th. — The  patient  was  removed  to  his 
home,  where  he  made  a  rapid  and  perfect  recovery.  In  March,  1887,  a  slight  degree 
of  catarrh  of  the  neck  of  the  bladder  was  cured  by  irrigation  with  permanganate-of- 
potash  lotion.     The  patient  remained  well  ever  since  then. 

Case  IV. — Joseph  Goldstein,  aged  sixty-six,  bladder  trouble  of  old  standing.  Cal- 
culus is  diagnosticated  by  the  sound.  Fair  general  condition.  August  8,  1888. — Epi- 
cystotomy  at  Mount  Sinai  Hospital.  Kemoval  of  two  large  uratic  calculi,  weighing 
together  1,190  grains.  Tardy  closure  of  wound.  Patient  discharged  cured,  October 
5,  1888.  A  sinus  leading  down  into  the  bladder  reopened  three  times,  but  ultimately 
healed  in  the  spring  of  1889. 

Case  V. — Mr.  George  L.,  musician,  aged  tifty-seven.  In  July,  1888,  vesical  calcu- 
lus was  diagnosticated.  August  15,  1888. — Epicystotomy.  Eemoval  of  uratic  stone 
weighing  201  grains.     Slight  iodoform  intoxication.     Cured,  September  16,  1888. 

Case  VI. — Samuel  Bader,  tanner,  aged  twenty-seven.  July  6,  1888. — Removal  of 
sarcoma  of  trigomus  by  transverse  incision  at  Mount  Sinai  Hospital.     Died  August  15, 

1888,  of  septicaemia.     Autopsy  revealed  left  multiple  pyonephrosis. 

Case  VII. — Julius  Basch,  actor,  aged  thirty-five.  January  81,  1890. — Removal  of 
diffuse  papilloma  of  bladder  at  Mount  Sinai  Hospital.  In  spite  of  double  pyonephrosis, 
wound  was  healed  May  28,  1890.  Long-continued  drainage  seems  to  have  somewhat 
abated  the  kidney  trouble,  as  there  was  no  fever  since  March,  1890. 

Case  VIII. — Solomon  Loewenthal,  janitor,  aged  fifty-four.  October  28,  1887. — 
Dpper  cystotomy  at  Mount  Sinai  Hospital  for  chronic  prostratic  ulcer  and  extreme  irri- 
tability of  bladder  under  ether  anaesthesia.  Died  of  acute  lobar  pneumonia  (autopsy) 
November  6,  1887. 

Case  IX. — Solomon  Posner,  tailor,  aged  thirty-seven,  suprapubic  cystotomy. 
liovember  2,  1888. — At  Mount  Sinai  Hospital  for  tubercular  cystitis.     Died  February  5. 

1889,  after  nephrectomy  (see  history,  page  282). 

Case  X. — Linche  Kester,  tailor,  aged  twenty-seven,  chronic  cystitis  with  irritable 
bladder.  August  2,  1888. — Perineal  cystotomy  at  Mount  Sinai  Hospital.  Discharged 
with  closed  wound  and  much  improved  condition  of  bladder,  September  17,  1888. 


PART    II. 


ANTISEPSIS. 


CHAPTER   VI. 


NATURAL  HISTORY  OF  IDIOPATHIC   SUPPURATION. 

SUPPURATION. 


TREATMENT   OF 


I.     THE    CAUSE    OF    SUPPURATION    OR    PHLEGMON. 

It  would  far  transcend  the  limits  of  these  essays  to  enter  into  a  detailed 
presentation  of  all  vegetable  organisms  known  to  lead  a  parasitic  existence 
in  the  living  human  body.  But  a  few  glimpses  into  this  new  world  of 
beings,  more  or  less  hostile  to  human  health  and  life,  may  be  welcome 
to  the  busy  practitioner,  who  lacks  time  or  ojiportunity  for  independent 
research. 

Eosenbach's  classical  investigations  have  revealed  the  fact  that  the  most 
common  source  of  suppuration  is  the  implantation  and  thriving  in  the  living 
human  tissues  of  a  minute  globular  fungus  or  micrococcus,  called  from  the 


'■>«.^l" 


Fig.  129. — Microscopical  as- 
pect of  staphylococcus  au- 
reus aad  albus.  (Under 
the  microscope  their  ap- 
pearance is  identical.) 
(From  Eosenbach.) 


Fig,  130. — Streptococcus  pyogenes. 
(From  Eosenhach.) 


Fig.  131.  —  Chain  -  coccus 
of  erysipelas  (Fehleisen). 
(From  Eosenbach.) 


Fig.  132.— Bacillus  of  pu- 
trescence. (From  Eosen- 
bach.) 


jA 


Fig.  133. — Bacilli  taken  from  a  pu- 
trid bone-abscess  in  general  sepsis 
(962  diameters).  (From  Eosen- 
bach.) 


Fig.  134.  —  Bacilli  from 
emphysematous  gangrene. 
(From  Eosenbach.) 


golden  yellow  color  of  the  mold  it  forms  on  a  peptonized  meat-agar  culture- 
soil,  ^'  StajjTiylococcus  pyogenes  aureus,''^  or  the  golden  grape-cocmis.  It  is 
called  gTape-coccus  [staphyle,  grape)  on  account  of  the  agminated  or  bunched 
arrangement  of  the  single  cocci  that  comj)ose  a  colony.     (Fig-  129.) 


184 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


This  coccus  is  found  in  almost  all  forms  of  acute  suppuration — in 
phlegmon,  glandular  abscesses,  and  in  acute,  infectious  osteomyelitis.  By 
certain  methods  of  manipulation,  a  pure  or  unmixed  culture  of  this  fungns 
can  be  raised  upon  glass  plates  covered  with  a  film  consisting  of  a  mixture 

of  peptonized  meat-jelly 
and  agar  agar,  a  vegeta- 
ble form  of  gelatin.  This 
mold  resembles  in  struct- 
ure the  common  form  of 
mold  dreaded  by  house- 
keepers, only  it  has  a 
deep  orange  color.  It 
has  the  peculiarity  of 
thriving  upon  the  living 
human  tissues,  causing 
their  inflammation  and 
ultimate  death.  (Plate  I,. 
Fig.  1.) 

Another  form  of  grape- 
coccus,  not  so  common 
as  the  preceding  one,  and 
appearing  either  alone  or 
associated  with  the  gold- 
en grape-coccus,  is  Eosen- 
bach's  "  Staphylococcus 
pyogenes  albus."  It  can  not  be  distinguished  from  the  yellow  coccus  under 
the  microscope,  but  the  mold  produced  by  pure  culture  is  easily  recognized 
by  its  pearly  white  color.     (Plate  I,  Fig.  2.) 

Both  forms  of  grape-coccus  have  the  clinical  peculiarity  of  causing  well- 
localized  foci  of  phlegmon.  All  tissues  within  a  certain  area  become  uni- 
formly permeated  by  the  grape-coccus.  They  coagulate,  then  emulsify,  and 
the  result  is  a  distinct  abscess. 

Another  form  of  micro-organism — Rosenbach's  ''  Streptococcus  pyogenes,'^ 
or  pus-generating  chain-coccus — is  so  called  on  account  of  the  arrangement 
of  the  single  globular  cocci  in  more  or  less  elongated  chains.  (Fig.  130.)  Its 
laeculiarity  is  to  rapidly  extend  along  the  lymph-spaces  and  lymphatic  ves- 
sels. Its  emulsifying  property  is  not  as  pronounced  as  that  of  the  grape- 
coccus,  but  it  may  become  very  destructive  to  the  tissues  by  rapid  infiltra- 
tion along  the  lymphatics,  causing  progressive  gangrene.  The  peculiarity 
of  extending  along  the  course  of  the  lymph-vessels,  as  well  as  its  micro- 
scopical appearance,  testify  to  its  close  morphological  relation  with  the 
streptococcus,  or  chain-coccus  of  erysipelas,  discovered  by  Fehleisen.  (Plate 
I,  Fig.  3,  and  Plate  II,  Fig.  4;  then  Fig.  131.) 

Pure  cultures  of  the  pus-generating  streptococcus  and  the  coccus  of  ery- 
sipelas diifer  ver}'  distinctly  in  several  important  points  (see  Plate  II,.  Figs. 
4  and  5),  but  microscopically  they  can  not  be  distinguished. 


Fig.  135. 


-Bacilli  of  putrefaction  and  diverse  forms  of  cocci 
in  putrid  blood.     (Koch.) 


Plate  I. 


Fig.  1.— Pure  culture  of  gold-colored  grape-coccus  of  suppuration  from  a  furuncle  of  the 

lip,  on  meat-peptone-agar,  seen  by  reflected  light. 
Fig.  2. — White  grape-coccus  by  reflected  light. 
Fig.  3.— Chain-coccus  of  pyemia  by  reflected  light.    (From  Rosenbach.) 


NATURAL  HISTORY  OF  IDIOPATHIC  SUPPURATION.        185 


None  of  tlie  pus-generating  cocci  cause  what  is  commonly  called  putres- 
cence. Decomposition  of  tissues,  accompanied  hy  the  production  of  foul 
odors,  is  always  due  to  the 
fermentative  action  of  di- 
■verse  forms  of  elongated  bod- 
ies, called  bacilli  or  bacteria. 
Plate  III,  Fig.  8,  shows  a 
pure  culture  of  the  "Bacil- 
lus saprogenes,"  or  bacterium 
•of  putrescence.  Fig.  9  is  a 
pure  culture  gained  from  an 
osteal  focus  in  putrid  com- 
pound fracture  with  fatal 
septicemia.  (Figs.  132  and 
133.) 

The  accomiDanying  chro- 
molithographs were  careful- 
ly copied  from  Eosenbach's 
monograph,  and  give  a  very 
life-like  image  of  the  several 
molds  or  cultures. 

On  account  of  their  ex- 
cellence and  truthfulness,   a 


Fig.  136. — Bacteria  of  blue  pus  (700  diameters).     (Koch.) 


number  of  Koch's  renowned  microphotographs,  illustrating  various  forms 
•of  microbial  growth,  have  been  here  reproduced. 


n.     PORTALS    OF    INFECTION. 

It  is  safe  to  assume  that,  without  exception,  all  forms  of  suppuration 
owe  their  origin  to  infection  from  without.     The  portals  through  which 

the  pyogenic  organisms 
known  as  cocci  and  bac- 
teria enter  the  system 
are,  on  one  side,  the  le- 
sions of  the  outer  integu- 
ment ;  on  the  other,  le- 
sions of  the  mucous  lin- 
ing of  the  digestory,  re- 
spiratory, and  urogenital 
apparatus.  The  infection 
of  larger  accidental  or 
surgical  wounds  has  been 
treated  of  in  the  preceding  chapters.  Infection  through  minimal  lesions  of 
the  skin  or  mucous  membranes  and  its  sequelae  will  now  receive  attention. 

1.  Infection  through  Lesions  of  the  Skin. — The  popular  tenet  that  a 
wound  that  bleeds  well  heals  well,  is  based  on  correct  observation.     Sharp 


Fig.  137. — Human  kiclney  in  pyelo-nephritis.     In  the  center, 
urinary  canal  filled  with  cocci  (700  diameters).     (Koch.) 


186  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

hemorrhage  is  very  apt  to  dislodge  and  carry  off  particles  of  filth  deposited 
in  the  wound  from  without  at  the  time  of  the  injury  ;  and,  further,  it  sig- 
nifies an  abundant  blood  supply,  good  nutrition,  hence  prompt  union.  An- 
other point  of  importance  is,  that  wounds  that  bleed  profusely  generally 
come  under  the  care  of  a  physician,  and  will  receive  at  once  proper  atten- 
tion and  protection  from  further  injury. 

Small  abrasions,  lacerations,  or  punctured  wounds  that  bleed  very  little, 
or  not  at  all,  have  deservedly  a  bad  reputation.     If  the  injuring  instrument 
or  object  does  not  inoculate  the  wound  with  filth,  and  subsequent  infection 
is  prevented  by  proper  measures,  healing  will  proceed  without  interruption. 
But  as  a  rule,  these  wounds  are  neglected  from  the  outset,  because  there 
is  scanty  or  no  haemorrhage.     The  sharp-edged  tool  of  the  mechanic,  or 
the  pointed  object  handled  in  the  daily  vocation  of  the  laboring  man   is 
very  rarely  clean.     In  certain  occupations,  as  that  of  the  butcher   anato- 
mist, or  cook,  the  hands  are  frequently  injured  while  m  contact  with  ioul 
orcranic  substances,  and  the  injuring  force  will  at  the  same  time  inoculate 
filth.     No  hemorrhage  following,   and  the  pain  being  insignificant,  the 
matter  is  lightly  passed  over,  and  work  proceeds  without  interruption.     Ihe 
cleansin-  effected  by  hemorrhage  is  absent,  the  small  orifice  of  the  skin  is 
soon  filled  by  lymph  and  obliterated,  and  we  have  to  deal  with  a  hermetic- 
ally sealed  focus  containing  filth,  leavened  by  a  certain  number  of  micro- 
organisms, that  at  once  must  and  do  begin  to  develop  and  multiply,  causing 
a  destructive  purulent  inflammation.  ,      .      .  mi. 

Not  all  of  these  small  injuries  are  infected  from  the  beginning.  They 
may  and,  as  their  frequent  spontaneous  healing  proves,  are  often  enough 

^'^  A^a  matter  of  fact,  they  do  well  at  first,  and  as  long  as  the  patient  takes 
care  of  them.  But  if,  as  often  happens,  the  protecting  scab  is  remjured, 
and  infection  by  contact  with  foul  matter  follows,  the  consequence  is  sup- 
puration. 

NoTE-Inflamruatory  lesions  of  the  skin  are  fruitful  sources  of  infection,  among  them 
eczema  the  foremost.  The  intense  itching  leads  irresistibly  to  scratching,  and  the  small  excoria- 
tions thus  produced  are  often  the  portals  of  infection. 

2  Infection  through  Lesions  of  the  Mucous  Membranes. -Less  numerous 
than  the  lesions  of  the  skin,  yet  productive  of  frequent  mischief,  are  the 
traumatic  and  inflammatory  lesions  of  the  mucous  membranes,  bhght 
injuries  to  the  lips,  tongue,  buccal  and  faucial  mucous  membrane  are  very 
common.  In  most  cases  a  profuse  flow  of  saliva  is  instantly  produced  by 
a  painful  injurv,  and,  if  hemorrhage  be  also  present,  infection  rarely  takes 
place  Healthy  oral  cavities  and  their  adnexa  are  especially  exempt  from 
infectious  processes  following  injuries.  Even  gunshot  wounds  of  these  parts 
can  heal  without  suppuration  under  favorable  circumstances  : 

Case  -E  L  a^ed  eighteen,  admitted  to  Mount  Sinai  Hospital,  December  7,  1884 
with  suicidal  fresh  pistol-shot  wound  of  the  tongue,  extending  from  the  tip  backward 
to  the  left  side  of  the  base,  dividing  the  organ  in  two  unequal  parts.    Gunshot  pertora- 


Fig.  4. — Culture  of  ehaiu-coecus  from  a  case  of  acute  progressive  gangrene.    Transmitted 

light. 
Fig.  5. — Chain-eoccus  of  erysipelas  (Fehleisen).    Transmitted  light. 
Fig.  6. — Chain-coccus  of  erysipelas  by  reflected  light.    (From  Rosenbach.) 


NATUEAL  HISTORY  OF  IDIOPATHIC  SUPPUEATION.        187 

tion  of  the  pillars  of  the  fauces  of  the  left  side ;  gunshot  wound  of  the  posterior  pharyn- 
geal wall,  the  point  of  entrance  situated  just  back  of  the  faucial  pillars  of  the  left  side, 
about  an  inch  and  a  quarter  from  the  median  line,  all  of  these  injuries  being  produced 
by  a  bullet  of  22  mm.  caliber.  A  second  non-penetrating  gunshot  wound  on  the  fore- 
head without  a  point  of  exit.  Free  haemorrhage  from  the  tongue,  and  also  a  stream 
of  arterial  blood  from  the  pharyngeal  wound.  The  latter  being  in  close  vicinity  to  the 
left  internal  carotid  artery,  tbe  left  common  carotid  was  tied  at  once  as  a  preventive 
measure,  mainly  with  a  view  to  the  possibility  of  subsequent  suppuration  and  second- 
ary hfemorrhage.  The  perfect  condition  of  the  teeth  and  oral  mucous  membrane  was 
noted.  The  lingual  wound  was  lightly  rubbed  over  with  a  small  sponge  dipped  in 
iodoform-powder ;  the  pharyngeal  wound  icas  not  probed,  and  hourly  irrigation  of  the 
oral  cavity  with  weak  salt  water  was  practiced.  Profuse  sweating,  perhaps  due  to 
reflex  vasomotor  disturbance,  set  in,  and  persisted  for  about  forty- eight  hours.  The 
febrile  movement  was  very  shght,  and  both  the  operation  wound  and  the  gunshot 
wound  on  the  forehead,  being  redressed  on  December  loth,  were  found  healed  and 
dry  under  their  iodoform  dressings.  The  lesion  of  the  tongue  was  found  granulating 
and  contracting,  the  perforation  of  the  pillars  of  the  fauces  nearly  closed,  the  point  of 
entrance  in  the  posterior  pharyngeal  wall  firmly  occluded  by  a  fresh-looking  blood- 
clot.  Breath  odorless.  December  21st. — The  flattened  ball  removed  by  small  incision 
from  the  top  of  the  head,  where  it  could  be  felt  beneath  the  skin.  The  entire  track 
of  this  projectile  had  literally  healed  without  suppuration.  The  pharyngeal  wound 
found  also  cicatrized  over,  the  ball  being  imbedded  near  and  below  the  left  transverse 
process  of  the  atlas,  in  close  proximity  to  the  vertebral  and  internal  carotid  arteries. 
The  head  was  held  inclined  to  the  right  side,  erection  of  the  spine  and  its  flexion  to 
the  left  being  impossible  on  account  of  the  intense  pain  caused  by  the  attempt.  This 
functional  disturbance  diminished  to  such  an  extent  within  a  few  months  that  the  con- 
templated extraction  of  the  small  projectile  was  abandoned. 

Had  the  patient's  oral  cavity  been  f onl  from  putrid  processes  accompany- 
ing an  acnte  or  chronic  oral  catarrh,  due  to  dental  caries  or  other  causes, 
suppuration  of  the  pharyngeal  wound  would  have  been  very  probable.  The 
danger  would  have  been  very  much  graver  on  account  of  the  possibility  of 
■extension  of  the  suppuration  and  the  likelihood  of  uncontrollable  secondary 
lisemorrhage.  A  probing  of  similar  ivoiincls  luitJiout  a  clear  and  necesmry 
object  in  vieiu  is  ahvays  a  dajigerous  and  ijivariably  useless  step,  and  should 
be  refrained  from  under  almost  all  circumstances.  TTe  may  use  a  clean 
probe,  and  the  probe  may  not  be  the  carrier  of  infection  ;  but  its  introduc- 
tion will  break  down  the  blood-clot,  the  natural  barrier  provided  by  the 
organism  itself  against  infection,  and  the  probe  will  leave  behind  an  open 
•channel  for  the  eatrance  of  possibly  fetid  oral  mucus  into  the  narrow  wound. 

!N'ext  in  frequency  to  the  inflammations  in  and  about  the  oral  cavity 
and  its  adnexa  are  those  due  to  injuries  and  other  lesions  about  the  anal 
and  uro-genital  orifices. 

m.  ENTRANCE,  PROGRESS,  AND  LOCALIZATION  OF  THE 

INFECTION. 

As  long  as  the  integrity  of  the  epidermis  is  j^reserved,  no  infection  from 
without  will  take  place.  The  integrity  of  the  epithelial  covering  of  the 
mucous  membranes  does  not  seem  to  have  the  same  protective  power  as  the 

26 


188 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


epidermis.  This  may  be  explained  by  the  fact  that  slight  injuries  of  the 
mucous  lining  are  produced  much  more  easily  than  those  of  the  skin,  and 
are  not  readily  ascertained  on  account  of  the  normally  moist  condition  of 
the  parts. 

As  formerly  stated,  the  slightest  denudation,  not  deep  enough  to  cause 
haemorrhage,  and  just  productive  of  a  slight  exudation  of  serum,  offers  a 
favorable  point  of  entrance  to  the  virus  in  the  patulous  orifices  of  the 
lymphatic  vessels  or  lymph-spaces,  thus  exposed  by  the  injury. 

In  lacerations  or  2)anctured  wounds  the  infective  agents  are  very 
often  deeply  inoculated  with  the  point  of  the  injuring  article — that, 
is,  they  are  at  once  deposited  in  close  vicinity  to  deep-seated  lymph- 
vessels. 

In  the  more  superficial  forms  of  injury,  the  implantation  of  the  virus, 
occurs  only  in  the  neighborhood  of  more  superficial  lymphatics,  and  its. 
transmission  to  the  deeper  lymph-vessels  is  accomplished 
by  forces  which  govern  the  flow  of  lymph  from  the  pe- 
riphery to  the  center.  Aside  from  the  normal  current  set- 
ting toward  the  thoracic 
duct,  external  forces  and 
the  play  of  the  volun- 
tary muscles  have  an  im- 
portant part  in  hasten- 
ing the  flow  of  lymph. 
So,  for  instance,  the 
pressure  exerted  upon 
the  lymphatics  of  the 
palm  by  the  frequent 
and  vigorous  grasping 
of  a  tool  wielded  for  a 
long  time  with  great 
force,  will  undoubtedly 
help  to  propel  the  con- 
tents of  the  peripheral  lymphatics  toward  the  larger,  more  deeply  situated 
lymphatic  trunks.  Or  the  vigorous  contractions  of  the  muscles  during 
mastication  will  undoubtedly  empty  the  adjacent  lymphatics  centerward, 
their  action  being  aptly  comparable  to  that  of  a  force-pump. 

What  was  formerly  danoted  as  external  meclianical  irritation  is  nothing 
but  this  forci7ig  of  pus-generating  substances  into  the  open  lymphatics  by 
friction  or  other  pressure  due  to  exercise. 

The  direction  and  extent  of  the  spread  of  the  infection  by  the  lymphatics 
are  prescribed  by  the  anatomical  arrangement  of  the  lymph-vessels  of  the 
region  concerned.  Thus,  on  the  palmar  aspect  of  a  finger,  the  poisoning 
will  rapidly  extend  to  the  j^eriosteum,  as  the  lymphatics  all  tend  that  way. 
In  the  vicinity  of  lymph-glands,  the  infection  will  promptly  extend  to  them, 
an  intervening  lymphangitic  streak  often  clearly  denoting  the  route  \>j 
which  it  traveled. 


Fig.  138.- 


-Bacilli  of  anthrax  and  streptococcus 
(700  diameters).     (Koch.) 


Fifi.  7.— Mixed  culture  of  golden  and  lemon  colored  and  of  white  grape-coccus  from  a 

case  of  empyema.     Reflected  light. 
Fig.  8.— Common  organism  of  putrescence.     Bacillus  saprogenes.     Reflected  light. 
Fig.  9. -Bacillus  saprogenes  from  a  focus  of  septic  compound  fracture.     Septic»mia. 

Reflected  light.     (From  Rosenbach.) 


NATURAL  HISTORY  OF  IDIOPATHIC  SUPPURATION.        189 

The  Tarving  intensity  of  the  infection,  dependent  on  hitherto  unkuoTvn 
and  yarying  fermentative  qualities  of  different  cultures  of  micro-organisms, 
will  also  greatly  influence  the  rapidity  and  virulence  of  the  inflammatorv 
process.  So  much  is  well  established  that  the  intensity  of  the  infection 
depends, _^r-s-f,  on  the  virulence  of  the  invading  culture  of  bacteria  ;  secondly, 
on  the  quantity  of  fungi  absorbed  :  and,  thirdly,  on  the  j^ower  of  resist- 
ance— that  is,  the  state  of  health  of  the  invaded  organism. 

Mechanical  Irritation. — Meclianical  irritation  hy  foreign  substances 
imbedded  in  tissues,  such  as  bullets,  splinters  of  glass,  or  a  broken-off  point 
of  a  knife-blade,  is  also  a  myth  in  the  old  meaning  of  the  phrase.  They 
never  cause  suppuration  unless  infectious  siibstances — that  is,  microbial 
filth — be  adherent  to  them  at  the  time  of  their  being  deposited  in  the  tis- 
sues. They  may  cause  pain  by  pressure  upon  nerves,  or  may  interfere 
with  the  play  of  a  joint  or  a  mtiscle,  but.  as  a  rule,  never  will  cause  in- 
flammation or  suppuration.  Well-disinfected  steel  nails,  driven  by  mallet 
through  femur  and  tibia  after  exsection  of  the  knee-joint,  are  unhesitat- 
ingly left  imbedded  for  thirty  or  more  days,  never  causing  any  irritation 
(see  Exsection  of  Knee- Joint,  page  319.) 

Case. — In  1882  a  young  blacksmith  presented  himself  in  the  surgical  division  of 
the  German  Dispensary.  An  angular  foreign  body  could  be  distinctly  felt  under  the 
skin  on  the  palmar  aspect  of  the  right  forearm,  midway  between  elbow  and  wrist. 
causing  pain  by  impinging.  The  body  had  appeared  only  since  a  few  weeks.  Near 
the  carpus  a  transverse  cicatrix  was  to  be  seen,  and  the  patient  explained  that  he  was 
cut  there  during  a  drunken  brawl  two  years  ago,  and  that  a  surgeon  had  tied  an  artery 
and  sewed  up  the  wound,  which  had  healed  without  suppuration.  Ever  since  then  he 
had  worked  at  his  trade  without  any  inconvenience  until  within  a  few  days.  From 
the  incision  made  over  the  projecting  body,  a  blackened  knife-blade,  four  inches  long 
and  five  eighths  of  an  inch  wide,  was  extracted,  to  the  greatest  astonishment  of  the 
patient.     The  small  wound  closed  promptly. 

Here  we  saw  a  massive,  sharp-edged  foreign  body  lie  imbedded  for  two 
years  between  the  muscles  of  the  forearm  without  any  inconvenience  to  the 
patient,  until  the  angular  base  of  the  blade  had  worked  out  tinder  the  skin. 
"Why  did  it  not  cause  suppuration  ?  Apparently  the  blade  must  have  been 
newly  grotmd,  or  at  any  rate  very  clean,  when  it  broke  off  in  the  arm  of 
our  blacksmith.  Had  a  considerable  amount  of  infection  been  carried  along 
with  it  at  the  time  of  the  injury,  its  presence  would  not  have  been  over- 
looked so  long. 

Dead  organic  substances,  as,  for  instance,  blood,  or  cubes  of  animal  tis- 
sues, such  as  muscle,  tendon,  or  portions  of  liver  or  bone,  were  taken  from 
a  freshly  killed  animal,  and  introduced  into  the  abdominal  cavity  of  a  num- 
ber of  other  rabbits  under  strict  antiseptic  precautions.  In  a  very  large 
proportion  of  cases  no  reaction  whatever  followed.  The  animals  being 
killed,  it  was  found  that  blood  was  absorbed  outright ;  that  muscle,  liver, 
tendon,  and  bone  were  encapsulated  ;  and  that  their  structttre  was  gi-adually 
invaded  by  granulation  tissue — disintegration  and  final  absorption  follow- 
ing after  a  while,  proportionate  to  the  density  of  the  implanted  bodies.     In 


190  RULES  OF  ASEPTIC  AND   ANTISEPTIC  SURGERY. 

cases  where  the  ordinary  aseptic  measures  had  been  omitted,  septic  purulent 
peritonitis  followed  as  a  rule. 

Note. — The  most  remarkable  of  Dr.  H.  Tillmann's  experiments  (Virchow's  "  Archiv,"  Bd. 
Ixxviii,  1879)  is  that  concerning^  a  rabbit,  in  the  abdomen  of  which  an  entire  rabbit's  liidney  was 
deposited  witliout  causing  any  harm  whatever.  Tlie  animal  being  killed  forty-seven  days  after 
the  operation,  the  implanted  kidney  w'as  sought  for  in  vain,  as  it  had  disappeared  by  absorption, 
the  only  vestige  of  its  former  presence  being  a  spot  of  tough  cicatricial  tissue,  denoting  the 
locality  where  the  foreign  body  was  attached  by  exudations. 

This  experimental  observation  is  fully  borne  out  by  the  experience  gained 
in  numberless  ovariotomies,  where  massive  pedicles,  dead  through  stoppage 
of  their  circulation  by  ligature,  are  dropped  back  harmlessly  in  the  perito- 
naeum, to  be  finally  absorbed — that  is,  they  will  do  no  harm  if  a  culture 
of  bacteria  is  not  deposited  on  them  by  the  operator. 

Chemical  and  Caloric  Irritation. — The  common  experience  that  certain 
acutely  irritating  substances,  as,  for  instance,  croton-oil,  oil  of  cantharides, 
turpentine,  concentrated  solutions  of  corrosive  sublimate,  and  others, 
brought  in  contact  with  living  tissues,  always  would  produce  suppuration, 
represented  a  serious  gap  in  the  theory  of  the  microbial  origin  of  suppura- 
tion. If  invariably  proved,  it  would  be  more  than  a  defect,  as  it  would 
positively  contradict  the  thesis  that  suppuration  is  exclusively  and  always 
the  result  of  the  development  of  micro-organisms.  The  experiments  of 
Councilman,*  who  introduced  under  the  skin  of  animals  small  glass  globes 
filled  with  sundry  irritating  substances,  and  then  crushed  them,  all  led  to 
suppuration.  Scheuerlen  f  and  Klemperer,J  however,  in  going  over  Coun- 
cilman's experiments,  showed  that  his  procedure  was  faulty,  inasmuch  as 
suflBcient  precautions  had  not  been  taken  to  exclude  the  introduction  of 
microbes  along  with  the  croton-oil,  etc.  They  moreover  positively  demon- 
strated by  a  very  large  number  of  successful  experiments  that,  whenever 
thorough  aseptic  cautelae  were  observed,  suppuration  never  followed  the  in- 
troduction of  even  very  considerable  quantities  of  the  mentioned  substances. 
Small  quantities  caused  some  exudation  of  plasm,  and  then  were  absorbed 
outright.  Afterward  the  fragments  of  the  glass  receptacle  were  found  im- 
bedded in  a  film  of  new-formed  connective  tissue.  Larger  quantities  of 
croton-oil,  for  instance,  caused  a  coagulation  necrosis  of  a  limited  mass  of 
tissue,  which  was  found  dense,  bloodless,  and  of  a  yellow  color.  These 
nodes  of  necrosed  tissue  were  gradually  absorbed,  suppuration  never  foUoio- 
ing  the  experiment.  This  fact  is  in  full  accord  with  other  incontestable 
facts  of  the  same  character,  as,  for  instance,  the  absorption  of  necrosed 
ovarian  stumps  in  the  abdominal  cavity  if  there  be  no  microbial  infection 
present. 

Caloric  irritation,  or  even  an  outright  destruction  of  tissues  by  exces- 
sive heat,  presents  a  similar  state  of  things.  As  long  as  microbial  infection 
is  successfully  kept  away  from  the  exudations  in  burns  of  a  milder  charac- 

*  Virchow's  "Archiv,"  1883,  vol.  xcii,  p.  217. 

\  "  Archiv  fiir  klin.  Chirurgie,"  vol.  xxxii,  p.  500. 

\  Prize  essay,  Berlin  University,  "Zeitschr.  fiir  klin.  Med.,"  1885,  vol.  x,  p.  158. 


XATVEAL   HISTORY   OF   IDIOPATHIC   SUPPUEATIOX.        191 

ter.  and  from  rhe  eschar  and  exudations  iu  severer  forms,  no  suppuration 
will  follow.  The  modern  use  of  the  thermo-eautery  in  the  peritoneal  cavitv. 
in  joints,  and,  a5  a  matter  of  fact,  in  wounds  of  the  most  various  character 
and  of  all  anatomical  regions,  is  followed  by  uninterrupted  union  in  all 
cases  where,  at  the  same  time,  adequate  aseptic  measures  are  emploved. 
An  eschar  or  a  mass  of  dead  tissue,  whether  produced  by  ligature,  or  chemi- 
cal corrosion,  or  red  heat,  will  never  assume  the  irritating  character  of  a 
''' foreign  body,"'  in  the  meaning  of  the  term  as  presented  by  the  tenets  of 
an  older  pathology,  if  the  decompiosing  action  of  the  presence  of  micro- 
organisms is  excluded  by  proper  measures. 

The  behavior  of  superficial  iiwus  of  the  slcin  is  fully  iu  accord  with  the 
facts  Just  presented. 

If  a  bleb  be  raised,  and  is  left  unhroken  and  dry,  its  contents  will  be 
absorbed,  and  the  epidermis  will  settle  back  into  its  normal  relation  to  the 
cutis.  It  will  torn  into  a  dry  scale,  and  will  peel  oS  within  ten  to  twelve 
days,  exposing  the  tender  new  epndermis. 

How  different  is  the  course  of  a  burn  if  the  epidermis  is  torn  off  by  acci- 
dent or  intentionally,  and  the  exudations  are  thus  exposed  to  the  invasion 
of  micrococci  I  If  the  surgeon  do  not  employ  timely  disinfection  and  the 
application  of  a  protective  dressing,  suppuration  of  the  exposed  ctitis.  with 
all  its  accompaniment  of  pain,  long-contintted  granulation,  and  a  very  tardy 
healing,  will  follow. 

rv.     DEVELOPMENT    OP    PHLEGMON. 

From  the  moment  that  a  snfficient  qtiantity  of  active  ftmgi  have  estab- 
lished themselves  within  the  living  tissues,  remarkable  local  and  general 
phenomena  develop,  known  under  the  name  of  infiammation  and  septic 
fever. 

Our  object  is  not  research  into,  but  rather  a  lucid  explanaiiou  of.  the 
essence  of  inflammation,  as  understood  and  accepted  by  contemporary  ati- 
thorities.  iBence  a  brief  sketch  of  the  leading  features  of  the  process  is 
deemed  sufficient. 

Micrococci  find  a  most  favorable  pabttlum  in  dead  or  devitalized  organic 
substances.  The  living  tissues  off'er  a  decided  resistance  to  the  ravages  of 
the  micro-organism.  The  spontaneotis  limitation  and  occasional  unaided 
cure  of  some  forms  of  suppurative  inflammation  prove  this  assertion. 

Bacteria  can  not  thrive  on  the  products  of  decomposition  :  they  need 
for  their  sustenance  dead  but  uudecomposed  albuminoid  substances.  As 
soon  as  the  supply  of  dead  animal  tissue  is  exhatisted.  the  micro-organisms 
starve  and  perish.  Their  spores  or  seeds  are  left  behind  dormant,  but  will 
become  active  if  fresh  pabulum  is  offered  under  favorable  circumstances. 

This  explains  the  fact  that  fresJi  cadavers  or  animal  substances  in  tJie 
recent  stages  of  putrescence  are  much  more  infectious  than  those  that  are  in 
a  progressed  state  of  decomposition.  The  varving  intensity  of  different  cases 
of  infection  seems  to  depend  in  a  great  measitre  upon  the  varying  degrees 


192 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


of  vitality  of  different  microbial  cultures.  It  seems  to  admit  little  doubt 
that  the  great  majority  of  dangerous  wound  infections  are  brought  about  by 
the  importation  of  considerable  masses  of  very  active,  rapidly  proliferating 
micro-organisms  in  the  shape  of  "lumps  of  dirt,"  as  Lister  graphically  puts 
it,  taken  from  various  sources  of  recent  putrescence,  so  abundant  in  all 
human  surroundings.  The  dry  spores  floating  in  the  air  will  be  easily  taken 
care  of  by  the  living  tissues,  if  pollution  of  the  wound  hj  gross  dirt — that 
is,  masses  of  organic  matter  in  active  decomposition — is  avoided. 

Every  injury  causing  a  wound  destroys  the  vitality  of  those  cells  that 
lie  in  the  direct  path  of  the  cutting  or  lacerating  object.  The  blood  and 
lymph  exuded  from  the  vessels  coagulate,  and  also  represent  dead  matter. 

If  a  number  of  active  micrococci  are  implanted  into  the  bottom  of  the 
wound,  they  will  at  once  multiply,  using  the  blood-clot  and  its  extensions 
into  the  blood-vessels,  together  with  the  adjacent  dead  or  devitalized  tissues, 
as  a  welcome  soil  for  their  development.  This  fermentative  decomposition 
produces  from  its  very  beginning  certain  alkaloids  or  chemical,  extremely 
poisonous  substances,  the  iJtoma'ines,  that  are  very  diffusible.  By  dint  of 
this  diffusibility,  the  adjacent  vasomotor  nerves  at  once  come  under  their 
toxic  influence,  as  the  result  of  which  their  strong  dilatation  ensues,  which 
becomes  manifest  in  the  shape  of  an  active  hypcrcemia,  "  rubor. '' 


Fig.  130. — Bacilli  of  anthrax  (Ti'ii  diameters). 
( Koch. ) 


Fig.  l-iC. — Formation  of  spores  in  anthrax 
bacilli  (700  diameters).     (Koch.) 


The  blood  passing  through  the  adjacent  arterioles  and  capillaries  seems 
also  to  become  altered  ;  the  red  blood-corpuscles  become  packed  and  finally 
stagnate  in  the  capillaries  and  smaller  arteries.  The  walls  of  these  vessels, 
including  the  veins,  lose  their  impermeabilitv,  and  a  number  of  white  and 
often  red  blood-corpuscles  emigrate  into  the  surrounding  tissues,  densely 
infiltrating  their  interstices,  thus  producing  the  characteristic  siceUing, 
"  turgor. ^^ 

As  a  consequence  of  the  increased  blood-supjoly,  possibly  also  of  the 
active  chemical  process,  a  marked  increase  of  the  local  temperature  is  ob- 
served— "  calor.''     And,  if  we  add  that  pain  of  the  parts  thus  affected  is 


NATURAL  HISTORY  OF  IDIOPATHIC  SUPPURATION.        193 

never  absent,  we  have  completed  the  classical  cycle  of  the  four  cardinal 
symptoms  of  inflammation — "  ruior,  color,  turgor,  dolor.'" 

Note. — The  causes  of  local  pain  may  be  several.  The  initial  pain  is  very  likely  due  to  a 
direct  influence  of  the  ptomaines  upon  the  sensory  filaments.  Direct  pressure  caused  by  the 
dense  infiltration  may  also  have  some  influence ;  but  the  most  acute  pain  is  undoubtedly  effected 
by  the  actual  destruction  of  the  nerve-tissue  during  the  advanced  stages  of  suppuration. 

Stagnation  and  dense  infiltration  finally  produce  a  very  high  degree  of 
tension,  leading  to  compression  of  larger  afferent  vessels.  The  infiltrated 
portions,  devitalized  by  suppression  of  the  normal  circulation,  readily  suc- 
cumb to  the  inroads  of  the  millions  of  micro-organisms,  and  actual  necrosis 
rapidly  follows.  The  last  stage  of  textural  destruction  is  the  final  liquefac- 
tion of  the  tissues  and  infiltrating  leucocytes,  aided  by  the  exudation  of 
large  quantities  of  lymph-serum  from  the  adjacent  unobstructed  blood-ves- 
sels, and  thus  the  formation  of  an  abscess  or  a  cavity  filled  witli  lymph- 
serum,  myriads  of  dead  white  blood-corpuscles  (pus-cells),  and  quantities  of 
shreds  of  necrosed  tissues,  is  accomplished. 

The  veins  also  participate  in  the  disturbance.  Coagulation  of  their  con- 
tents— thrombosis — takes  place,  and  existing  stagnation  is  materially  aug- 
mented. 

The  deleterious  part  played  by  thrombi  in  the  causation  of  metastases 
will  be  later  mentioned. 

When  a  septic  inflammation  of  sufficient  extent  and  intensity  has  been 
well  advanced,  the  great  tension  of  the  parts  will  necessarily  cause  an  over- 
flow of  the  most  diffusible  contents  of  the  focus  into  the  surrounding  effer- 
ent vessels — the  veins  and  lymphatics.  The  ptomaines,  thus  entering  the 
general  circulation,  will  at  once  produce  systemic  intoxication,  manifested 
by  a  very  marked  rise  of  the  body-heat,  rigors,  sickness,  headache,  delirium, 
and  general  dejection — in  short,  a  deep-going  alteration  of  the  nervous 
system,  known  as  septic  fever. 

V.     SPREAD    OF    SUPPURATION. 

The  way  of  the  extension  of  septic  textural  destruction  is  twofold.  It 
takes  place,  first,  by  a  direct  infiltration  of  the  tissue-interstices  by  columns 
and  hosts  of  the  immensely  prodigious  micrococci — that  is,  by  an  immedi- 
ate growth  and  extension  of  the  microbial  colony  ;  and,  secondly,  on  the 
way  of  the  lymphatics,  openly  communicating  with  the  focus  of  suppura- 
tion. Into  these,  bacterial  masses,  or  pus  charged  with  micrococci,  are 
forced  by  the  hydrostatic  pressure  exerted  by  the  tension  within  the  abscess. 

If  the  ]oarts  affected  are  composed  of  loose  tissues,  the  spread  will  be 
rapid  and  extensive  ;  if  the  parts  are  dense,  the  inflammation  will  remain 
localized  as  long  as  the  density  of  the  tissues  (fascise,  for  instance)  will  resist 
the  pressure  of  the  secretions.  But,  as  above  mentioned,  this  very  pressure, 
or  tension,  involves  another  great  danger.  The  afferent  blood-vessels  become 
thereby  occluded,  and  the  resulting  stagnation  generally  leads  to  extensive 
necrosis. 


194  RULES  OF  ASEPTIC   AND  ANTISEPTIC  SURGERY. 

As  long  as  new  areas  of  tissue  become  infected  througli  the  lymphatics, 
constant  high  fever  and  increase  of  the  local  symptoms  is  the  rule.  An 
incision  laid  through  the  parts  at  an  initial  stage  of  the  process  will  expose 
a  honeycombed  mass  of  tissue,  containing  a  number  of  small  foci,  some  of 
them  confluent,  and  all  filled  with  pus,  the  interyening  substance  being 
discolored,  pale,  or  more  or  less  broken  down  and  softened,  or  sloughed. 

In  direct  proportion  with  the  spread  of  the  infection  and  the  multiplica- 
tion of  supjDurating  foci,  is  the  magnitude  of  necrosing  areas,  occasionally 
involying  an  entire  limb.  Organs  of  scanty  vascularity,  as,  for  instance, 
fasciae,  tendons,  and  bone,  are  the  first  to  succumb. 

The  microbial  colony  begins  to  show  signs  of  exhaustion  in  most  cases 
after  a  more  or  less  prolonged  period  of  florescence.  The  parasite  becomes 
less  prolific  ;  its  direct  ingrowth  into  the  tissues  is  less  and  less  active,  and 
the  life  of  the  white  blood-corpuscles,  densely  infiltrated  into  the  marginal 
parts  of  the  abscess,  is  not  compromised  by  their  invasion  with  micrococci. 
They  are  not  converted  into  pus,  but  withstand  the  attack  of  the  parasites 
and  remain  a  mass  of  embryonal  connective  tissue,  that  forms  a  dense  wall 
inclosing  the  suppurating  cavity.  This  embryonal  connective  tissue  uni- 
formly i^ermeates  all  the  adjacent  parts,  among  others  the  lymjihatics  and 
thrombosed  veins,  forming  a  more  or  less  effective  harrier  to  the  extensio7i  of 
the  septic  process  and  to  the  absori^tion  of  deleterious  soluble  substances  into 
the  general  circulation. 

This  self-limitation  of  tlie  spread  of  septic  destruction  is  generally 
marked  by  a  remission  of  the  intensity  of  the  general  and,  in  a  measure,  of 
the  local  symptoms.  At  this  stage,  according  to  ancient  notions,  the  abscess 
has  matured. 

Note  I. — For  obvious  reasons,  the  incision  of  a  mahircd  abscess  is  generally  followed  bv  a 
rapid  healing  of  the  cavity.  The  detachment  and  liquefaction  of  the  contents  of  the  abscess  are 
well  completed,  the  extent  of  the  process  is  well  rounded  off,  as  it  were,  by  the  wall  of  newly 
organized  connective  tissue,  and  repair  can  commence  under  favorable  circumstances. 

Nevertheless,  it  must  be  strongly  urged  that  the  most  dangerous  abscesses  never  ripen — that 
is,  show  no  tendency  to  self-limitation — and  that  the  measures  ordinarily  employed  for  maturing 
them,  such  as  vigorous  poulticing,  only  tend  to  intensify  their  malignity,  and  to  cause  irrepara- 
ble damage,  that  an  early  incision  might  have  averted.  A  case  vividly  illustrating  the  pernicious- 
ness  of  thoughtless  poulticing  is  quoted  on  page  248. 

Note  II. — Not  every  bacterial  infection  leads  to  suppuration,  although  the  rule  suffers  very 
few  exceptions  indeed.  One  of  the  exceptions  is  illustrated  by  the  following :  Case. — I.  N.,  laborer, 
aged  twenty- four,  was  admitted  to  the  German  Hospital  in  March,  1685,  with  a  very  painful, 
hard,  and  massive  swelling  of  the  axillary  contents,  the  skin  being  oedematous  and  angry-looking. 
High  fever  and  a  good  deal  of  sickness  were  observed,  so  that  pus  was  thought  to  be  indubita- 
bly present.  An  incision  was  declined,  whereupon  a  poultice  was  ordered,  with  the  expectation 
that  it  would  hasten  the  process  by  stimulating  suppuration.  For  a  day  or  two  the  intensity  of 
the  symptoms  increased  rather  than  otherwise,  several  sharp  chills  followed  with  profuse  sweat- 
ing, after  which  came  a  marked  improvement  of  all  the  appearances  of  the  case.  The  redness 
and  swelling  diminished,  the  fever  disappeared,  and  the  patient  left  the  hospital  cured,  glorying 
in  his  triumph  of  endurance  over  diagnostic  acumen. 

To  explain  such  cases,  it  is  necessary  to  assume  that,  under  the  powerful  stimulation  of 
the  local  circulation  by  the  cataplasm,  the  products  of  bacterial  fermentation,  bacteria,  or  even 
pus  itself,  are  washed  away  by  the  lymph-current  into  the  general  circulation,  where  the  pto- 


NATURAL  HISTORY  OF  IDIOPATHIC  SUPPURATION.        195 

maines  provoke  constant  or  explosive  symptoms  of  general  intoxication,  such  as  high  fever  or 
severe  chills ;  the  bacteria  themselves,  however,  perish,  the  living  oxidized  blood  forming  an 
unfavorable  pabulum  for  their  existence  and  propagation.  In  accord  with  this  theory  is  the 
well-known  fact  that  wounds  of  very  vascular  tissues,  such  as  those  of  the  face,  for  instance, 
will  heal  without  suppuration  even  when  there  is  a  good  deal  of  inflammation  of  their  edges, 
with  pain  and  fever,  denoting  the  presence  of  a  certain  amount  of  septic  infection.  The  poorer 
the  blood-supply  of  a  part,  the  greater  the  destruction  wrought  by  an  infectious  process. 

If  the  abscess  is  not  evacuated  at  the  stage  of  maturity  through  a  fortu- 
nate spontaneous  or  an  artificial  opening,  the  relief  felt  by  the  patient  will 
be  a  short-lived  one.  The  marginal  wall  of  embryonic  connective  tissue — 
that  is,  the  area  of  gj'anulations — will  continue  to  shed  lymph  and  detached 
leucocytes  into  the  abscess  cavity.  The  intramural  pressure  will  steadily 
increase  until  it  rises  to  such  a  degree  as  to  overcome,  on  hydrostatic  prin- 
ciples, the  resistance  of  the  soft  plugs  of  living  leucocytes,  which  occlude 
the  orifices  to  the  adjacent  connective-tissue  planes  and  lymphatics  or  veins. 
One  or  another  of  these  offering  the  least  resistance,  will  be  forced  out  of 
the  way,  and  a  new  invasion  of  hitherto  unaffected  regions  results,  with  a 
repetition  of  all  the  initial  local  and  general  symptoms,  marking  an  exten- 
sion of  the  process. 

Note. — The  notion  that  the  law  of  gravity  alone  regulates  the  spread  of  abscesses  is  an  erro- 
neous one,  as  it  is  well  known  that  many  forms  of  suppuration  extend  in  a  diametrically  opposite 
direction  to  the  force  of  gravity.  The  local  spread  is  prescribed  by  the  direction  of  the  loose 
connective-tissue  planes  separating  and  connecting  the  different  organs,  and  is  mainly  influ- 
enced by  hydrostatic  law.     Perforation  always  takes  place  where  resistance  is  the  least. 

The  infiltration  of  the  tissues  by  micrococcal  colonies  sometimes  extends 
to  the  close  vicinity  or  into  the  very  walls  of  larger  veins.  Thrombosis  is 
the  direct  result,  and,  if  the  microbial  invasion  includes  the  thrombus,  after 
the  detachment  of  the  slough  of  the  vein  and  the  liquefaction  of  the  throm- 
bus, a  direct  communication  of  the  general  circulation  with  the  abscess 
cavity  may  be  established.  The  slightest  external  pressure  may  serve  to 
throw  enormous  masses  of  pus  and  micro-organisms  into  the  general  circula- 
tion at  this  critical  period,  causing  raj^id  death  by  explosive  septicaemia. 
In  these  cases  the  microscojoe  will  demonstrate  the  presence  of  micrococci 
in  the  entire  blood-mass. 

In  other  cases,  either  spontaneously  or  in  consequence  of  active  move- 
ments or  external  manipulations,  a  portion  of  a  septically  infected  thrombus 
may  be  detached.  The  blood -current  will  at  once  carry  it  into  the  right 
auricle  and  ventricle,  whence  it  will  find  its  way  into  one  or  another  branch 
of  the  pulmonary  artery,  to  be  there  arrested  in  the  shape  of  an  embolus. 

Around  this  a  hsemorrhagic  infarction  of  the  adjacent  pulmonary  tissues 
will  form,  within  which  a  new  bacterial  colony  will  become  established, 
leading  to  the  formation  of  a  secondary  or  metastatic  abscess.  Its  appear- 
ance is  always  signalized  by  a  severe  rigor. 

Thrombosis  of  adjacent  pulmonary  veins,  and  detachment  of  portions  of 
the  new  thrombus,  followed  by  its  transportation  into  the  left  side  of  the 
heart,  and  hence  into  distant  smaller-sized  arteries  of  the  body,  will  lead  to 
27 


196  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

a  repetition  of  the  metastatic  process  and  its  febrile  accompaniment,  until 
a  number  of  joints,  lymph-glands,  the  liver,  in  fact,  almost  all  the  organs, 
become  the  seat  of  secondary  abscesses. 

This  is  the  classical  type  of  well-developed  pijcemia,  formerly  so  common 
in  all  surgical  hospital  wards,  but  now  become  a  rare  phenomenon  wherever 
the  leaven  of  the  Listerian  spirit  has  permeated  surgical  practice. 

This  form  of  microbial  colonization  of  the  entire  human  body  baffles 
every  plan  of  treatment,  and  almost  invariably  leads  to  the  destruction  of 
the  organism.  It  is  as  good  as  incurable,  hut  it  can  be  prevented  ;  hence  it 
is  the  moral  duty  of  every  physician  to  do  everything  in  his  power  to  avert 
this  form  of  mischief. 

Note. — Recovery  of  a  case  of  well-developed  pt/cemia  is  so  rare  that  recording  the  following 
case  seems  permissible.  The  notes  were  kindly  furnished  by  Dr.  A.  Caille,  with  whom  the 
author  saw  the  patient  in  consultation  at  his  home  in  Williamsburg : 

"  Henry  Huhn,  an  elderly  man.  Enormous  carbuncle  over  left  scapula ;  necrosis  of  fasciae 
and  subcutaneous  connective  tissue  from  clavicle  to  seventh  rib  posteriorly,  the  result  of  three 
weeks'  neglect  (poulticing). 

"Energetic  treatment  (by  Dr.  Caille)  with  knife  and  irrigation  (carbolic).  Well-marked 
symptoms  of  pyaemia ;  general  furunculosis  of  trunk. 

"Auffust  16, 1S80. — Consultation  with  Dr.  Gerster,  who  advised  tonic  treatment  and  daily 
full  baths  in  loeak  hichloride-of -mercury  solution,  together  with  frequent  irrigations  with  cam- 
phorated water.  Temperatures  at  this  time  on  an  average  102°  Fahr.  Pulse,  120  to  140.  Dysp- 
noea, chills,  and  sweats.  Improvement  noticeable,  but  slow.  In  September,  suppuration  of 
almost  all  the  lymph-glands  took  place  within  one  week,  without  redness  or  tenderness,  so  that 
at  one  time  a  tenotomy  knife  introduced  almost  anywhere  would  draw  pus.  Subsequently  exten- 
sive and  painful  periostitis  and  abscess  at  upper  third  of  right  tibia  developed.  About  this  time 
examination  of  urine  revealed  a  large  percentage  of  sugar.  The  patient's  diet  was  properly 
regulated,  and  his  urine  was  free  from  sugar  five  months  later.  Mr.  11.  has  since  been,  and  is 
to-day  (December  23,  1886),  in  excellent  health." 

It  will  be  noticed  that  a  methodical  use  of  a  mercuric  lotion  was  advised  by  the  author  sev- 
eral years  before  Kuemmel's  and  Schede's  experiments  brought  corrosive  sublimate  so  promi- 
nently to  the  notice  of  the  medical  world  as  an  excellent  disinfectant.  The  recommendation 
was  based  upon  the  long-known  good  influence  that  corrosive  sublimate  has  upon  acne  pustu- 
losa  of  the  face.  Its  application  in  the  shape  of  a  full  bath  suggested  itself  by  the  extension  of 
the  affection  to  almost  the  entire  skin,  and  by  the  enormous  difficulty  in  cleansing  and  dressing 
the  innumerable  sores  of  the  patient.  Since  that  time  the  author  has  employed  the  permanent 
bath  in  another  similar  case,  to  the  great  relief  of  the  patient  and  his  attendants.  Twice  daily 
the  bath  was  charged  with  corrosive  sublimate  (1  :  5,000)  for  an  hour,  after  which  the  solution 
was  drawn  off,  and  substituted  with  a  weak  salicylic  lotion.  The  remarkable  relief  brought 
about  by  the  immersion  of  the  entire  body  was  due  to  the  circumstance  that,  f7-si,  the  frequent 
and  extremely  painful  change  of  dressings  could  be  dispensed  with ;  and,  secondly,  that,  accord- 
ing to  hydrostatic  law,  the  buoyancy  of  the  immersed  body  relieved  to  a  very  great  extent  its 
presszire  upon  the  couch  spread  in  the  bottom  of  the  bath-tub.  The  spread  of  the  bed-sores 
ceased.  Before  his  attack,  the  patient  had  been  in  very  weak  health.  After  three  or  four  seiz- 
ures by  collapse,  relieved  by  increase  of  the  temperature  of  the  bath  to  110°  Fahr.,  he  suc- 
cumbed to  heart  failure. 

The  contents  of  the  preceding  pages  have  in  a  rough  way  illustrated  the 
essence  of  cellular  phlegmon,  or  the  suppuration  of  connective  tissue,  inele- 
gantly denoted  in  text-books  as  ''cellulitis.'" 

For  obvious  reasons  lymphatic  glands  very  often  become  the  seat  of 
microbial  proliferation.     Their  direct  communication  with  a  numerous  set 


NATURAL  HISTOEY  OF  IDIOPATHIC  SUPPURATION.       197 

of  lymphatics  and  their  filter-like  structure  naturally  lead  to  ready  absorp- 
tion and  detention  of  noxious  substances.  In  this  characteristic  is  to  be 
sought  a  by  no  means  insignificant  protective  quality  of  the  lymphatic 
glands  against  general  invasion  of  the  body  by  microbial  masses. 

The  difference  exhibited  by  lymph-gland  abscesses  in  comparison  with 
the  ordinary  forms  of  phlegmon  is  due  to  their  anatomical  structure  and 
situation.  Their  strong  capsule  will  resist  destruction  for  a  comparatively 
long  time,  thus  preventing  for  a  while  invasion  of  the  vicinal  tissues.  But 
the  internal  tension  of  a  glandular  abscess  soon  becomes  very  great,  and  will 
lead  to  extensive  mortification  by  compression  of  vessels. 

The  anatomical  situation  of  many  lymph-gland  abscesses,  their  deep  seat 
and  close  vicinity  to  large  vessels,  the  pleura,  the  fauces,  and  larynx,  invest 
them  with  additional  importance,  both  as  regards  the  danger  peculiar  to 
their  locality,  and  the  technical  difficulty  of  their  treatment. 

The  skeleton  is  fortunately  a  comparatively  rare  seat  of  bacterial  infec- 
tion. The  fearfully  dangerous  and  destructive  character  of  acute  infectious 
osteomyelitis,  or  "bone  phlegmon,"  is  due  to  the  rigidity  and  unyielding 
nature  of  the  periosteum  and  bone  tissue,  which  lead  to  rapid  occlusion  of 
the  blood-vessels,  and  extensive,  often  widely  disseminated  necrosis.  The  deep 
situation  of  the  bones  renders  the  symptoms  of  this  form  of  suppuration  ex- 
tremely violent  and  dangerous,  and  increases  the  difficulties  of  treatment. 

Note  I. — The  so-called  habituation  of  butchers,  cattlemen,  and  anatomists  to  infection  seems 
to  be  based  rather  on  structural  changes  of  the  skin  of  their  hands  frequently  exposed  to  con- 
tamination, than  to  a  real  habituation,  such  as  is,  for  instance,  brought  about  by  vaccination 
against  the  small-pox.  That  the  system  of  these  persons  does  not  become  hardened  or  accus- 
tomed to  the  septic  virus  is  proved  by  the  fact,  that  phlegmonous  processes  will  readily  establish 
themselves,  and  develop  in  the  ordinary  way,  if  the  infection  occur  elsewhere  than  on  their  hands. 
A  more  plausible  explanation  of  this  apparent  immunity  will  be  found  in  the  state  of  the  lym, 
phatics  of  the  integument.  Having  been  the  seat  of  frequent  more  or  less  intense  attacks  of 
inflammation,  they  become  obliterated  and  distorted,  as  it  were,  by  cicatricial  changes  in  and 
around  them.  That  recent  or  old  cicatricial  formations  do  not  possess  large-sized  lymph-vessels 
is  well  known,  hence  absorption  through  them  of  corpuscular  elements  into  the  deeper  lymphatics 
will  be  difficult  and  scanty.  In  short,  the  chronically  inflamed  state  of  the  skin  covering  the 
hands  of  these  persons  offers  in  its  infiltrated  condition  an  effective  protection  against  the  deep- 
going  or  massive  implantation  of  micro-organisms  through  superficial  lesions. 

Parallel  with  this  state  of  things  seems  to  be  the  well-known  fact  that  children  subject  to 
frequent  attacks  of  septic  tonsillitis  or  diphtheria  rarely  succumb  to  the  disease.  Penetration 
by  bacterial  elements  of  the  dense  cicatricial  tissue  left  behind  by  many  preceding  attacks  is 
difficult,  and  absorption  of  the  ptomaines  through  the  scanty  lymphatics  is  very  limited.  Hence 
the  process  soon  becomes  exhausted  through  lack  of  pabulum  lo  the  microbial  growth.  A  cer- 
tain quantity  of  viable  spores  remain  imbedded  in  a  follicle,  to  again  develop  their  activity  as 
soon  as  a  simple  catari'hal  inflammation  of  the  pharynx  will  have  prepared  the  soil  for  their 
renewed  growth. 

Diphtheria  in  children  who  never  had  been  subject  to  the  disease  is  a  much  more  serious 
matter.  Unchanged  tissues  with  open  lymphatics  are  attacked  here.  The  conditions  for  local 
microbial  proliferation  and  invasion  of  the  tissues,  and  for  absorption  and  systemic  intoxication, 
are  much  more  favorable  then,  and,  as  is  well  known,  often  lead  to  unavertable  death. 

The  comparative  safety  of  all  operations  performed  within  the  limits  of  a  preceding  but 
terminated  inflammation — that  is,  within  recent  or  older  cicatricial  tissue — is  very  well  known 
to  all  surgeons.     Rearaputations,  many  joint  exsections,  almost  all  necrotomies,  rarely  give  any 


198  KULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

serious  trouble,  even  if  the  antiseptic  measures  taken  were  not  very  complete.  The  infection 
of  an  amputation  wound  made  through  healthy  tissues  is  much  more  serious,  and  its  avoidance 
more  difficult,  as  countless  lymphatics  and  large,  newly  opened,  intermuscular,  loosely  knit 
connective-tissue  planes  offer  numerous  recesses  and  countless  channels  for  the  reception  and 
unimpeded  extension  of  infection. 

Therefore  the  statistics  of  amputation  wounds  have  been  very  appropriately  selected  as  a 
uniform  and  reliable  test  of  the  value  of  the  different  forms  of  wound  treatment. 

Note  II. — Infection  through  minute  injuries  to  a  gramdating  surface  by  inoculation  of  active 
micrococci  is  the  frequent  cause  of  suppurations  interrupting  the  course  of  repair.  Rough  treat- 
ment of  a  granulating  wound  by  tearing  off  the  adherent  dressings  will  necessarily  lacerate  the 
tender  granulations  matted  into  the  meshes  of  the  fabric,  thus  causing  minimal  hcTmorrhage. 
If  an  unclean  probe,  or  finger-nail,  or  nitrate-of-silver  stick,  previously  used  on  a  virulent  case, 
and  then  applied  to  the  granulations,  should  carry  and  deposit  some  active  micrococci  into  one 
of  these  minute  lesions,  an  ulcerative  process  of  the  granulations  will  ensue,  and,  if  the  ulcera- 
tion extend  into  adjacent  tissues,  phlegmon  will  develop.  Gramdations  should  always  he  covered 
by  "  protective  ^^  before  the  application  of  gauze  or  other  dressings. 

Conclusions. 

Suppuration  is  always  undesirable  and  dangerous,  and,  if  possible,  should 
be  avoided  by  all  means.  Its  essence  is  textural  destruction  and  death,  and 
systemic  intoxication.  The  i:)hrase  "  healing  by  suppuration  "  is  an  absurd- 
ity, is  misleading  to  the  student,  and  should  be  banished  from  text-books. 
As  a  matter  of  fact,  healing  never  takes  place  while  active  suppuration  lasts  ; 
it  occurs  only  after  the  limitation  and  termination  of  suppuration,  not  by 
it,  but  in  spite  of  it. 

The  expression  "laudable  pus,"  as  applied  to  the  contents  of  an  abscess 
during  one  of  its  stages  of  spontaneous  limitation  or  maturing,  is  also  mis- 
leading. Pus  is  never  laudable  ;  it  always  is  a  menace  to  the  health  and 
integrity  of  the  animal  organism.  Suppuration  is  a  treacherous  ally,  and 
its  aid  should  never  be  invoked  by  the  modern  surgeon,  or  at  least  should 
be  shunned  as  long  as  other  ways  of  curing  an  ailment  remain  untried. 

VI.     DIAGNOSIS    AND    TREATMENT    OF    PHLEGMON. 

1.  General  Priticiples. 

The  way  to  the  cure  of  phlegmonous  processes  is  indicated  by  the  man- 
ner in  which  unaided  nature  occasionally  accomplishes  it.  If  the  direction 
in  which  suppurative  destruction  progresses  should  luckily  be  outward — 
that  is,  toward  the  skin — perforation  and  spontaneous  evacuation  of  the 
abscess  cavity  will  occur.  If  by  another  lucky  accident  this  perforation 
should  happen  at  the  time  of  "maturity,"  or  the  comparative  repose  of  the 
destructive  process,  a  complete  evacuation  of  the  deleterious  contents  will 
take  place,  followed  by  a  decreasing  sero-purulent  and  bland  discharge,  and 
by  contraction  and  final  occlusion  of  the  cavity. 

But  nature  unaided  is  a  very  poor  surgeon.  Very  often  destruction 
does  not  tend  toward  the  skin  ;  its  natural  tendency  is  to  spread  in  the  di- 
rection of  least  resistance,  that  is,  along  the  cellular  tissue,  and,  by  the  time 
that  spontaneous  ojoenings  establish  themselves,  the  damage  to  deep-seated 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  199 

organs  may  be  very  extensive.  The  coincidence  of  maturity  and  perforation 
is  also  rare.  In  its  absence  the  perforation  will  not  lead  to  complete  evacua- 
tion, and  the  septic  process  will  persistently  extend  in  one  or  another  direc- 
tion, not  relieved  by  such  incomplete  drainage.  Lastly,  natural  drainage  by 
perforation  will  often  be  located  in  the  most  unfavorable  place,  and  will  not 
be  ample  enough  for  the  escape  of  large  masses  of  pus  and  of  sloughing  tissue. 

The  most  direct  indications  for  the  cure  of  phlegmon  are  offered  by  a 
clear  understanding  of  the  natural  history  of  its  causation  and  development, 
as  presented  in  the  foregoing  pages. 

One  or  more  properly  made  incisions,  folloiued  hy  effective  drainage,  will 
at  once  empty  the  focus  of  most  of  its  infectious  contents,  relieving  at  the 
same  time  the  dangerous  amount  of  tension. 

Infected  tissues  not  yet  liquefied,  and  still  adherent  to  the  walls  of  the 
abscess,  must  be  disinfected  by  more  or  less  frequent  or  permanent  irriga- 
tion with  a  germicidal  lotion.  Finally,  all  conditions  tending  to  impede 
free  arterial  and  venous  circulation  must  be  eliminated  by  projDer  position 
— that  is,  elevation  of  limbs,  removal  of  constricting  dressings  or  clothing. 

The  necessity  of  rest — that  is,  the  avoidance  of  all  mechanical  injury — 
is  a  matter  of  course. 

(«)  Superficial  Suppuration,  or  Septic  Ulcer. — Inspissation  of  the  dis- 
charges of  an  infected  superficial  lesion  will,  by  the  formation  of  a  crust, 
often  prevent  proper  drainage,  causing  a  more  or  less  complete  occlusion 
or  retention.  The  gentlest  way  of  detaching  these  is  by  the  application  of 
a  warm  dressing  of  gauze  moistened  with  a  two-per-cent  solution  of  carbolic 
acid,  evaporation  of  which  should  be  guarded  against  by  an  external  layer 
of  rubber  tissue  or  oiled  silk.  After  due  softening  under  this  warm,  moist 
dressing,  the  overlapping  epidermidal  masses,  hiding  small  recesses,  should 
be  laid  open  by  cautiously  clipjiing  away  their  undermined  edges  with  curved 
scissors.  Tills  can  he  done  ivWiout  causing  the  least  'pain.  Thorough  dis- 
infection by  the  lotion  contained  in  the  dressings  will  thus  be  possible,  and 
the  diffusible  qualities  of  carbolic  acid  will  not  fail  to  exert  their  beneficial 
disinfecting  influence  upon  the  germs  scattered  through  the  vicinity  of  the 
ulcer.  Its  yellow  coating,  consisting  of  a  superficial  layer  of  mortified  tis- 
sues, will  be  cast  off,  the  angry  look  of  the  neighboring  skin  will  disappear, 
and  the  remaining  healthy  granulations  will  soon  be  cicatrized  over. 

StreaTcs  of  lymphangitis  extending  toward  the  pertinent  lymphatic  glands 
should  be  well  salved  with  mercurial  ointment.  But  if  their  cause — the 
septic  state  of  the  ulcer — be  removed,  they  will  disappear  without  special 
treatment. 

{b)  Cutaneous  and  Subcutaneous  Phlegmon. — This  graver  form  of  sup- 
puration is  marked  by  violent  local  and  general  symptoms.  High  fever, 
with  rigors,  the  general  sense  of  sickness,  headache,  and  a  foul  tongue  and 
breath  are  present.  The  skin  over  the  focus  of  infection  becomes  deeply 
inflamed,  cedematous,  and  shows  dense  infiltration,  manifested  by  hardness 
and  pitting.  The  constant  gnawing  pain  puts  sleep  out  of  the  question, 
and  the  spreading  of  the  affection  over  new  areas  of  tissue  is  evident. 


200 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


Cataplasm  or  Incision  ? 

The  question  whether  resolution  of  the  gathering  by  topical  applications, 
hot  or  cold,  should  be  attempted,  or  immediate  incision  should  be  resorted 
to,  is  of  great  practical  importance,  and  not  always  easy  to  determine. 

The  intensity  and  extent  of  the  process  should  he  herein  the  main  guide. 
The  consideration  that  an  incision  is  after  all  the  most  effective  antiphlo- 
gistic measure,  affording  relief  from  tension,  evacuating  a  very  large  pro- 
portion of  the  noxious  substances,  and  permitting  the  direct  application  of 
antiseptics — in  short,  that  it  promises  prompt  success,  conserves  a  large  part 
of  the  affected  tissues,  saves  much  pain  and  suffering,  and  averts  local  and 
general  danger — should  stand  foremost  in  the  surgeon's  mind,  whose  per- 
suasive authority  ought  to  gain  the  patient's  consent  to  an  early  operation. 
Especially  w^here  the  rapid  spread  of  the  affection  and  grave  general  symp- 
toms make  prompt  relief  urgent,  dilatory  measures  and  cowardly  tempor- 
izing are  improper.  The  cataplasm  is  resorted  to  not  only  to  allay  the 
patient's  paiti  and  fear,  but  often  serves  as  a  convenient  mantle  to  hide 
ignorance  or  indecision. 

Carbuncle  represents  the  most  pronounced  form  of  cutaneous  phlegmon, 
and  its  treatment,  given  hereunder,  may,  with  due  modifications,  serve  as 
a  type  of  the  therapy  for  the  entire  class  of  cutaneous  suppurations. 

Out  of  motives  of  humanity,  and  because  it  offers  the  surgeon  time  and 
deliberation,  so  necessary  for  thorough  work,  aneesthesia  is  always  advisable, 
— in  many  cases  indispensable.  After  the  usual  prejiarations  for  an  anti- 
septic operation,  a  free  incision  should  be  made  through  the  middle  of  the 

inflamed  area,  penetrating  through  the 
skin  to  the  fascia.  One  or  more  small 
foci  filled  with  pus  will  be  thus  opened. 
If  their  number  be  great,  two  or  three 
more  parallel  incisions  should  be  added. 
The  engorgement  or  hard  infiltration  of 
the  adjacent  skin  will  be  admirably  re- 
moved by  Yolkmann's  multiple  punctur- 
ing (Fig.  141).  The  blade  of  a  narrow, 
straight  bistoury  or  tenotomy  knife  is 
grasped  about  one  third  of  an  inch  from 
its  point,  and  is  thrust  in  quick  succes- 
sion thirty,  forty,  or,  in  very  extensive 
cases,  a  hundred  times  through  different 
parts  of  the  infiltrated  region.  The 
punctures  should  be  evenly  distributed.  A  large  quantity  of  bloody  lymph, 
or  occasionally,  if  a  vein  be  hit,  pure  blood  will  escape,  and  the  swelling 
and  hardness  will  at  once  be  markedly  reduced.  No  attempt  should  be 
made  to  check  this  escape  of  blood  or  serum,  as  coagulation  will  soon  stop 
the  flow.  Thorough  irrigation  with  corrosive-sublimate  lotion,  packing  of 
the  deeper  incisions  with  strips  of  iodoformed  gauze,  and  an  ample  moist 


Fig.  141. — Attitude  of  the  hand  for 
multiple  puncture. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  201 

dressing,  held  in  place  by  loose  turns  of  bandage,  will  complete  the  work. 
An  immediate  fall  of  the  temperature,  with  marked  local  and  general  relief, 
will  reward  both  patient  and  surgeon.  Daily,  later  on,  a  rarer  change  of 
dressings  will  lead  to  a  rapid  cure. 

If  the  patient  declines  an  operation,  tojDical  applications  are  in  order. 
Cold,  in  the  shape  of  iced  compresses,  or  the  ice-bag,  will  be  proper  where 
the  affection  is  superficial  and  accompanied  by  lymphangitis.  On  the  whole, 
it  may  be  said  that  cold  is  beneficial  in  the  initial  stages  of  most  phlegmon- 
ous affections,  and  is  often  very  well  borne  and  efficacious  in  the  milder 
forms.  To  many  it  becomes  unbearable  from  the  time  that  suppuration 
is  well  established,  and  often  induces  a  severe  chill,  the  real  cause  of  which, 
■however,  is  always  to  be  sought  in  the  presence  of  pus. 

Note. — Cold  is  badly  borne  by  elderly  or  run-down  subjects,  or  those  prone  to 
Theumatism. 

Dry  or  moist  heat  is  very  soothing  to  many  patients,  and  is  a  power- 
ful stimulant  to  the  local  circulation.  Occasionally  it  undoubtedly  averts 
threatening  suppuration,  and  may  aptly  be  employed  as  a  tentative  or  initi- 
atory measure.  However,  if  the  local  and  general  symptoms  continue  to 
increase,  it  should  not  beguile  the  surgeon  into  procrastination.  Especially 
if  a  gathering  become  so  massive  as  to  cause  fluctuation,  incision  should  not 
I)e  further  delayed. 

Note. — The  main  effect  of  the  curious  and  often  incomprehensible  combinations  of  sub- 
stances entering,  at  the  recommendation  of  laymen  and  some  physicians,  into  the  composition  of 
poultices,  seems  to  be  upon  the  faith  and  imagination  of  the  patient.  Moist  heat  is  their  active 
property,  and,  the  simpler  and  cleaner  its  employment,  the  better  it  will  be.  The  nauseous  prac- 
tice of  smearing  the  skin,  or,  still  worse,  a  wound,  with  hot  linseed  dough,  is  not  yet  extinct. 
Even  a  well-inclosed  poultice  is  not  a  proper  covering  to  a  wound,  unless  a  clean  cloth  and  clean 
mush  be  taken  for  each  application.  Certainly  a  mixture  of  soured  linseed  with  ichor  and  pus, 
inclosed  in  a  foul  rag,  is  the  worst  of  all  abominations  that  a  decaying  era  of  surgery  has  left 
"behind  as  its  legacy.  A  clean  cloth  dipped  in  and  wrung  out  of  hot  water,  covered  over  with  a 
piece  of  oiled  silk,  is  the  best,  the  cheapest,  and  the  least  unappetizing  of  all  cataplasms.  The 
cataplasm  should  never  be  placed  in  actual  contact  with  a  wound.  The  interposition  of  a  thin, 
moist  dressing  will  protect  the  wound  from  mechanical  insults  unavoidably  connected  with  the 
■change  of  poultice,  and  the  poultice  itself  will  thus  remain  unsoiled  by  the  secretions  of  the 
"wound. 

For  sjDecial  treatment  of  carbuncle,  see  i^age  224. 

Subcutaneous  phlegmon,  left  to  itself,  or  treated  by  too  long  poul- 
ticing, will  assume  very  large  proportions.  The  form  of  the  abscess  cavity 
is  rarely  globular,  but  mostly  irregular  and  sinuous.  This  is  partly  due  to 
confluence  of  several  smaller  abscesses,  partly  to  irregular  extension,  caused 
\)j  the  varying  density  of  the  subcutaneous  connective  tissues.  Fluctuation 
soon  appears,  and  without  delay  one  or  more  incisions  should  be  placed  so 
as  to  drain  every  recess  in  the  most  direct  manner.  Volkmann's  punctua- 
tion of  the  peripherical  infiltration  of  the  skin,  a  thorough  irrigation  of  the 
cavity,  and  a  moist  dressing,  constitute  the  treatment  of  these  cases.  The 
first  incision  is  made  where  fluctuation  is  most  marked ;  the  index-finger  of 
the  left  hand  is  then  cautiously  inserted,  and  carefully  explores  the  interior 


202 


RULES  OF  ASEPTIC  AND   ANTISEPTIC  SURGERY. 


of  the  abscess.  This  examination  is  very  important,  and  upon  its  result 
depends  the  locating  of  the  drainage-tubes.  Counter-incisions  are  made 
over  the  tip  of  the  left  index,  which  pushes  up  the  skin  from  witliin.  AU 
squeezing  of  the  abscess  at  this  stage  of  the  operation  should  be  carefully 
avoided.  After  the  placing  of  the  drainage-tubes,  and  a  thorough  irriga- 
tion, no  pus  should  be  contained  in  the  abscess.  If,  therefore,  gentle 
external  pressure  ^causes  the  escape  of  new  masses  of  pus,  this  is  a  sign  that 
one  or  more  recesses,  communicating  by  small  openings  ioith  the  main  cavity, 
remain  undrained,  and  need  further  attention.  They  must  be  located,  and 
separately  incised  and  drained. 

If  fluctuation  persist  over  one  or  more  places  in  the  vicinity  of  the  cen- 
tral abscess,  it  will  be  found  that  unopened,  independent  abscesses  require 

additional  incisions, 
f  iG.  u^.-Hikcm-Eoser^s  method  of  incL-ing  a  rj^j^g  j.Q^^g|^  tearing  and  break- 

ing down  of  septa  of  tissue  with- 
in the  abscess  by  the  surgeon's 
finger  is  unsafe,  on  account  of 
the  unnecessary  haemorrhage  it 
provokes,  and  because  it  may 
lead  to  pulmonary  embolism.  It 
is  better  to  make  a  sufficient 
number  of  counter-incisions. 

TJte  squeezing  out  of  abscess- 
es through  an  insufficient  spon- 
taneous or  artificial  opening  con- 
stitutes what  may  be  called  sur- 
gical barbarism.  If  the  opening 
is  too  small  or  improperly  placed, 
the  abscess  can  never  be  di'ained 
by  the  aid  of  the  law  of  gravity 
alone.  External  pressure  must 
be  employed  to  remove  its  con- 
tents, and  this  must  be  often 
repeated  to  prevent  refilling  of 
the  abscess.  As  "squeezing  out" 
is  a  very  painful  process,  the  pa- 
tient will  naturally  shrink  from 
it,  and  will  let  matters  go.  The 
abscess  becoming  nearly  filled, 
only  the  overflow  will  escape 
through  the  insufficient  aper- 
ture. The  result  is  slow  exten- 
sion of  the  suppurative  process, 
with  continuous  fever.  Dressings  of  any  kind  will  only  make  matters  worse, 
and  no  relief  will  follow  till  another  more  properly  located  artificial  or  spon- 
taneous opening  supply  the  defect  of  drainage. 


Fig.  14-3.— Completed  dressing  of  cervical  abscess. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON. 


203 


Fig.  144.- 


-Underpadding  of  safety-pins  thrust  through*  drainage- 
tubes  after  incision  of  cervical  abscess. 


The  best  proof  of  the  adequate  treatment  of  an  abscess  is  the  fact  that 
at  change  of  dressings  the  cavity  is  found  empty,  and  all  the  secretions  are 
contained    in     the 
dressings. 

The  frequency 
of  the  change  of 
dressings  should  be 
regulated  by  the 
amount  of  the  dis- 
charge. 

(c)  Deep  -  seat- 
ed or  Subfascial 
Phlegmon.  Lymph- 
Gland  Abscess.  — 
Still  more  serious 
than  subcutaneous 
suppuration  is  a 
phlegmonous  in- 
flammation of  the  superficial  or  deep-seated  lymphatic  glands,  or  the  sub- 
maxillary or  the  parotid  salivary  glands.  The  danger  of  these  forms  of 
septic  tissue-decomposition  consists  in  the  great  tension  which  their  pois- 
onous contents  attain  ;  the  difficulty  of  their  spontaneous  evacuation  on 
account  of  the  massive  barriers  interposed  between  them  and  the  surface  of 
the  body,  and  last,  but  not  least,  the  likelihood  of  their  perforation  into  the 
mediastinum,  pleura,  or  peritonaeum,  or  the  erosion  of  large  vessels  situated 
in  their  immediate  vicinity. 

Deep-seated  phlegmon  is  characterized  by  the  extremely  hard  and  deep- 
going  infiltration  of  the  superjacent  tissues,  a  general  and  massive  cedema 
of  the  soft  parts,  extending  far  beyond  the  limits  of  the  inflammatory  pro- 
cess, so  that  a  limb,  for  instance,  attains  double  its  size  ;  marked  functional 
disability  of  all  organs,  even  distantly  related  to  the  focus  of  disturbance, 
and  very  violent  symptoms  of  systemic  septic  poisoning. 

In  the  beginning  the  skin  covering  the  affected  locality  is  oedematous 
but  pale  ;  gradually  it  flushes  up  and  becomes  hard  and  brawny. 

Incision  and  drainage  is  the  sovereign  therapy  in  these  cases.  No  time 
should  be  wasted  in  attempts  at  an  abortive  treatment,  as  every  hour  of 
delay  may  cause  irreparable  damage.  The  distant  hope  of  resolution,  or 
the  desire  to  produce  "maturing"  by  poulticing,  should  not  be  allowed  any 
weight  in  the  face  of  the  knowledge  that  extensive  necrosis  is  the  unavoida- 
ble consequence  of  the  raj^idly  increasing  dense  infiltration  characteristic  of 
this  condition.  Relief  from  excessive  tension  is  the  first  and  most  urgent 
indication,  and  this  can  be  reached  only  by  an  incision. 

The  objection  that  these  abscesses  can  not  be  opened  safely  while  they 
are  small,  is  erroneous,  as  will  be  shown  directly.     But,  even  if  the  surgeon 
should  not  succeed  in  opening  the  small  cavity,  cutting  through  the  integu- 
ment and  fascia  will  do  material  service  by  averting  the  greatest  danger. 
28 


204  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

HiUon-Roser^s  method  offers  a  safe  and  easy  manner  of  evacuating  these 
foci.  Anaesthesia  is,  of  course,  indispensable.  A  free  incision  through  the 
skin  over  the  most  prominent  part  of  the  swelling  should  expose  the  fascia, 
which  should  also  be  divided  by  easy  strokes  of  the  point  of  the  knife  to  a 
sufficient  extent,  say  an  inch  or  two.  After  this  the  knife  is  laid  aside.  If 
a  small  aspirator  be  at  hand,  search  for  pus  can  be  made  by  puncturing  and 
aspirating  different  parts  of  the  swelling.  This,  however,  is  not  necessary. 
A  grooved  director  is  inserted  into  the  center  of  the  incision,  and  is  briskly 
thrust  into  the  swelling,  or,  if  large  vessels  be  near,  is  gradually  insinuated 
by  steady  rotating  pressure.  At  a  certain  point  resistance  will  suddenly 
cease,  and  a  drop  of  ichor  or  pus  will  be  seen  exuding  from  the  groove  of 
the  instrument.  A  dressing-forceps  should  now  be  placed  in  the  groove 
of  the  director,  and  should  be  pushed  into  the  focus.  The  grooved  director 
can  now  be  removed,  and  the  forceps  withdrawn  while  its  branches  are  held 
as  wide  open  as  jDOSsible.  A  gush  of  bloody  pus  will  follow  the  instrument. 
If  the  opening  be  too  small,  dilatation  with  the  dressing-forceps  should  be 
repeated  once  or  twice,  until  it  becomes  large  enough  to  admit  a  stout  drain- 
age-tube. Irrigation  and  a  moist  dressing  complete  the  procedure.  (Figs. 
142,  143,  and  144). 

If  the  incision  was  delayed  too  long,  the  relief  of  the  general  symptoms 
will  not  be  as  prompt  as  after  early  operations.  The  presence  of  adherent 
necrotic  tissues  explains  this  fact.  But  the  spread  of  the  mortification  is 
checked,  and  the  fever  will  abate  as  soon  as  the  sloughs  become  detached 
and  expelled. 

Very  numerous  applications  have  taught  the  author  the  great  value  and 
safety  of  this  method,  wliich,  therefore,  can  be  warmly  recommended. 

Fluctuation  is  a  very  late  symptom  in  all  deep-seated  abscesses,  and 
should  not  be  waited  for.  An  explorative  aspiration  of  a  doubtful  swelling 
will  generally  disperse  uncertainty,  and  the  production  of  pus  will  induce 
the  patient  to  consent  to  the  incision. 

The  haemorrhage  from  large,  deep-seated  abscesses  is  sometimes  copious. 
It  comes  from  the  walls  of  the  abscess  cavity,  which  are  very  vulnerable  ; 
hence  rough  exploration,  squeezing,  or  any  unnecessary  manipulations 
should  be  carefully  avoided. 

Note. — It  is  best  in  cases  of  great  emaciation  to  open  the  abscess  according  to  Hilton-Roser 
— to  insert  a  large-sized  tube,  and  to  desist  altogether  from  exploration  and  irrigation  until  a 
few  days  later.  The  cavity  will  contract,  its  contents  will  spontaneously  escape  toward  the  point 
of  least  resistance — that  is,  through  the  drainage-tube— to  be  absorbed  by  the  dressings,  and 
much  blood  will  be  saved  in  this  manner. 

Phlegmonous  Erysipelas. — A  combination  of  extensive  phlegmon  with 
true  erysipelas  is  not  very  common.  What  is  ordinarily  known  as  "phleg- 
monous erysipelas"  is  generally  nothing  but  a  very  extensive  subcutaneous 
phlegmon,  mostly  with,  sometimes  without,  subfascial  complications.  The 
worst  cases  are  directly  chargeable  to  prolonged  poulticing,  and  their  treat- 
ment is  rendered  very  difficult  by  the  frequent  occlusion  of  the  drainage- 
tubes  by  large  tow-like  masses  of  necrosed  connective  tissue  and  fascia. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON. 


205 


Gangrenous  phlegmoji  (Pirogoff's  acute  purulent  oedema)  represents  one 
of  the  highest  degrees  of  microbial  poisoning,  where  the  multiplication  of 
the   micro-orijanisms   is 


so 


rapid  and  pervad- 
ing that  the  establish- 
ment of  innumerable 
foci  throughout  all  of 
the  tissues  composing  a 
whole  limb  leads  to  ex- 
tensive general  infiltra- 
tion. Board-like  hard- 
ness, a  dusky  hue  of  the 
integument,  blebs  and 
ecchymoses,  and  finally, 
thrombosis  of  veins  and  arteries,  will  end  in  necrosis  of  the  entire  enor- 
mously swollen  and  cold  limb.  Incisions  do  not  yield  pus,  but  only  give 
vent  to  scanty  quantities  of  turbid  ichorous  serum.      In  these  cases  the 

prognosis  is  very  bad,  and 


Fig.  145. 


-Bacilli  of  malignant  cedema  or  acute  progressive 
phlegmon  (TOO  diameters).     (Koch.) 


Pig. 


146. — Bacilli  of  malignant  cedema  in  the  kidney 
(700  diameters).     (Koch.) 


the  most  heroic  incisions 
rarely  succeed  in  saving 
the  member.  If  too  long 
delayed,  even  a  high  am- 
putation may  fail  to  save 
the  patient's  life.  (Figs. 
145  and  146.) 

Empliysematous  Gan- 
grene.— The  inoculation 
of  the  human  organism 
with  a  specific  bacterium 
(Fig.  134)  is  generally  followed  by  the  development  of  a  dusky,  rapidly 
spreading  infiltration,  exhibiting  on  palpation  the  peculiar  crackling,  and 
on  percussion,  the  tympanitic  sound  of  subcutaneous  emphysema.  The 
process  is  accompanied  by  profound  septic  intoxication,  with  delirium,  high 
temperatures,  chills,  and  dejection,  and  terminates  in  gangrene  of  the 
affected  parts.  Eesolute  measures — that  is,  timely  amputation  performed 
through  healthy  parts — may  succeed  in  preventing  a  fatal  issue. 

{d)  Acute  Infectious  Osteomyelitis. — Suppuration  of  the  medullary  sub- 
stance of  parts  of  the  skeleton  represents  one  of  the  most  dangerous  and 
destructive  forms  of  phlegmon.  Its  cause  is  the  establishment  of  cult- 
ures of  the  gold- colored  grape-coccus  in  the  capillaries  or  arterioles  of  the 
marrow.  The  manner  in  which  this  infection  occurs  is  still  matter  of 
controversy.  So  much,  however,  is  known  that  it  is  most  common  during 
adolescence,  and  that  a  preceding  suppuration,  followed  by  exposure  to 
weather,  or  certain  traumatisms,  are  common  provocative  causes. 

The  invasion  is  marked  by  a  severe  chill,  followed  by  a  deep  alteration 
of  the  general  well-being.    Very  high  temperatures,  with  chills,  somnolency. 


206  EULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

a  dry  tongue,  foul  breath,  intense  gastric  disturbance,  bear  witness  to  the 
gravity  of  the  disorder.  The  insidiousness  of  the  local  and  the  gravity  of 
the  general  symptoms  lead  to  frequent  errors  of  diagnosis  on  the  part  of 
practitioners  who  never  have  seen  this  affection,  or  are  careless  observers. 
The  favorite  locality  of  the  disease  is  the  shaft  of  the  long  bones  near  one 
or  another  ejiiphysis,  as,  for  instance,  the  lower  end  of  the  femur.  This, 
together  with  the  upper  part  of  the  shaft  of  the  tibia,  is  its  classical  seat. 
No  bone,  however,  is  exempt  from  the  disorder. 

The  first  local  manifestation  is  a  deep-seated,  unbearable  pain,  soon  fol- 
lowed by  a  general  and  deep-going  oedema  of  all  the  soft  parts  overlying  the 
focus.  The  skin  is  pale.  As  the  soft  parts  covering  the  adjacent  joint  are 
also  swollen,  and  its  movement  is  painful,  the  erroiieoiis  diagnosis  of  acute 
articular  rheumatism  is  frequently  made. 

Often  the  patient  is  unconscious  or  quite  listless  at  the  time  of  the  phy- 
sician's first  visit,  and  the  local  symptoms  escape  attention.  As  a  matter 
of  fact,  typhoid  fever  or  meningitis  is  frequently  diagnosticated,  and  the 
affection  remains  unrecognized  until  the  appearance  of  a  fluctuating  swell- 
ing or,  in  extreme  cases,  spontaneous  perforation  of  an  abscess  disjiel  the 
error. 

The  essential  features  of  the  morbid  process  are  identical  with  those  of 
cellular  phlegmon,  modified,  however,  by  the  peculiar  structure  of  bone. 
On  account  of  the  rigidity  of  the  osseous  lamellae  inclosing  the  Haversian 
canals  ;  of  the  cancellous  and  cortical  substances  inclosing  the  medullary 
tissue,  and  of  the  periosteum,  the  dense  infiltration  and  massive  exudation 
will  rapidly  heighten  the  intraosseous  tension  to  such  a  degree  that,  the  ves- 
sels becoming  occluded,  more  or  less  extensive  necrosis  results. 

The  excessive  tension  of  the  noxious  exudations  penned  up  within  the 
rigid  tissues  will  cause  a  copious  overflow  and  absorption  of  plasm  charged 
with  ptomaines,  which  will  not  fail  to  cause  a  jjrofound  intoxication,  mani- 
fested by  very  grave  general  symptoms. 

Cortical  osteomyelitis,  or  what  is  known  in  text-books  as  suppurative 
periostitis,  is  the  mildest  form  of  the  affection,  and  is  most  amenable  to 
preventive  treatment.  The  necrosis  caused  by  it  generally  involves  the 
outer  part  of  the  bone  only,  jDroducing  a  cortical  sequestrum.  When  the 
epiphysis  is  attacked  in  the  vicinity  of  a  joint,  perforation  and  articular 
suppuration  may  occur  and  very  seriously  complicate  the  case. 

Case. — S.  C,  aged  twelve,  a  somewhat  ansemic  boy,  received,  December  19,  1882, 
a  kick  from  a  playmate  upon  the  spine  of  the  tibia,  which  caused  considerable  pain  for 
a  while,  but  no  discoloration.  The  next  day  a  severe  chill,  with  intense  local  pain 
and  an  extensive  hard  swelling  of  the  injured  region,  set  in.  The  boy  became  listless 
and  delirious ;  he  rapidly  emaciated ;  the  swelling  extended  in  all  directions.  The  author 
saw  the  patient  December  29,  1882,  in  consultation  with  the  family  attendant,  who, 
two  days  previous  to  this  meeting,  had  made  a  small  incision  corresponding  to  one  of 
the  many  points  where  perforation  of  the  skin  threatened.  The  boy  being  anaesthe- 
tized, a  free  incision  three  inches  in  length  was  made  by  gradual  preparation  down  upon 
the  anterior  surface  of  the  tibia,  beginning  a  little  below  the  patella.     Every  bleeding 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  207 

vessel  was  carefully  tied  at  once,  and  thus  clear  insiglit  and  much  bloodsaving  were 
■effected.  A  large  ulcerative  defect  of  the  periosteum  was  found  corresponding  to  a 
well-circumscribed  greenish-yellow  spot  of  the  tibia.  This  defect  extended  to  the  cap- 
sule and  into  the  knee-joint,  which  was  found  in  open  communication  with  the  sub- 
periosteal abscess,  and  was  distended  with  pus.  Two  incisions  were  made  into  the 
joint  for  purposes  of  drainage.  The  popliteal  space,  thigh,  and  calf  contained  a  num- 
ber of  burrowing  secondary  abscesses,  mostly  subcutaneous,  which  were  also  severally 
incised  and  drained.  The  entire  major  saphenous  vein  was  found  in  a  state  of  puru- 
lent phlebitis,  its  course  being  marked  by  a  chain  of  small,  angry-looking  swellings  of 
the  skin,  which,  on  being  opened,  all  yielded  pus.  As  it  was  probable  that  the  entire 
vein  would  suppurate,  it  was  slit  up,  beginning  from  the  ankle,  to  within  a  few  inches 
•of  Poupart's  ligament,  and  the  remaining  parts  of  the  thrombus  were  turned  out.  The 
"haemorrhage  from  entering  branches  was  checked  by  packing  with  narrow  strips  of 
iodoformed  gauze.  A  very  tardy  improvement  followed  these  extensive  measures. 
Jawiiary  10,  1883. — A  third  incision  into  the  upper  recess  of  the  knee-joint,  and  two 
more  counter-incisions  were  made  into  the  popliteal  space.  Large  masses  of  necrosed 
connective  tissue  came  away  at  almost  each  change  of  dressings,  and,  although  the 
febrile  disturbance  had  much  abated,  the  boy  seemed  to  steadily  lose  ground  on  account 
■of  the  enormous  suppuration.  The  cleansing  of  the  wounds  was  so  slow,  the  pain  and 
suffering  at  the  unavoidably  frequent  change  of  dressings  so  distressing  and  enervating 
to  the  patient,  that,  January  14th,  amputation  was  thought  of  as  a  last  resort.  The 
parents,  however,  firmly  declined  the  step,  and  fortunately  so,  as  the  boy  ultimately 
recovered,  with  anchylosis  of  the  knee-joint.  A  few  small  shells  of  necrosed  bone  came 
Away  from  the  epiphysis  previous  to  the  definitive  closure  of  the  wound. 

Central  osteomyelitis  is  much  more  destructive  to  the  osseous  tissue  than 
the  cortical  affection,  often  causing  necrosis  of  the  entire  shaft.  It  fre- 
quently extends  to  the  epiphysis,  and  involves  the  adjacent  joint. 

Note. — The  excruciating  pain  felt  by  the  patient  is  principally  due  to  the  tension  of  the 
periosteum,  separated  from  the  bone  by  more  or  less  pus.  Ordinarily,  the  extension  of  suppura- 
tion by  perforation  into  healthy  parts  is  marked  by  an  increase  of  the  local  and  general  suffer- 
ing. Not  so  in  osteomyelitis.  Perforation  of  the  periosteum,  and  evacuation  into  a  loose  plane 
of  connective  tissue,  is  always  marked  here  by  relief  of  the  intense  periosteal  pain,  and  often  by 
a,  temporary  decline  of  the  fever,  due  to  the  reduction  of  the  enormous  tension  which  first  pre- 
vailed. With  the  increase  of  the  tension  in  the  secondary  abscess  the  fever  rises  again,  but  the 
pain  never  reaches  its  former  intensity. 

Similar  relations  obtain  in  all  forms  of  suppuration  where  the  seat  of  the  morbid  process  is 
confined  by  dense  fascia  or  the  capsule  of  a  joint.  Submaxillary  and  parotid  cynanche,  septic 
inflammations  within  the  prepatellar  or  olecranic  bursge,  and  all  joint-suppurations  exhibit  the 
same  peculiarity.  As  long  as  the  suppurative  process  is  confined  within  the  mentioned  closed 
spaces,  the  tension  and  its  immediate  consequences — necrosis  and  copious  overflow  of  fever-gen- 
•erating  poisonous  material  into  the  lymphatics,  causing  intense  toxic  symptoms — are  at  their 
acme.  As  soon  as  perforation  and  partial  evacuation  of  incarcerated  pus  into  the  meshes  of  the 
vicinal  loose  connective  tissue  occurs,  a  relaxation  of  the  intense  pain  and  a  temporary  remis- 
sion of  the  septic  fever  are  observed. 

Can  Necrosis  he  averted  ? — Where  the  diagnosis  is  made  out  early,  where 
the  superficial  situation  of  the  bone — for  instance,  the  tibia — favors  a  precise 
localization  of  the  focus,  and  where  the  affection  is  cortical,  a  free  and  early 
incision  may  avert,  and,  as  a  matter  of  fact,  often  does  avert,  necrosis,  or  at 
least  will  prevent  its  extension.  In  the  beginning,  perhaps,  even  the  ravages 
of  central  osteomyelitis  could  be  limited  by  early  trepanning  of  the  medul- 


208  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

lary  space  in  one  or  more  places.  So  much  is  certiiiu  and  proved  by  experi- 
ence, that  prompt  incision  of  the  periosteum  and  trepanning  of  the  affected 
bone  admirably  relieves  the  acuity  of  the  local  and  general  symptoms. 

Case. — The  author  has  to  quote  from  memory  a  very  instructive  case  of  recent 
infectious  osteomyelitis  of  the  lower  end  of  the  humerus  observed  in  1880  in  the  surgi- 
cal department  of  the  German  Dispensary,  and  operated  in  the  presence  of  Dr.  W. 
Bnlser  and  other  colleagues.  A  young  woman,  exhibiting  an  unusual  degree  of  lassi- 
tude and  a  pitiable  facial  expression  of  suffering,  was  led  into  the  place  by  two  of  her 
friends.  Her  left  elbow -joint  was  semiflexed;  it  showed  a  pale,  dense,  and  uniform 
swelling.  Her  attendants  reported  that  she  had  had  a  severe  chill  in  the  morning  of 
the  preceding  day,  and  had  been  very  sick  ever  since  then.  The  thermometer  showed 
105°  Fahr.  in  the  axilla.  Extremely  acute  pain  was  complained  of  in  the  lower  end 
of  the  humerus.  Just  above  the  olecranon.  Osteomyelitis  being  diagnosed,  the  patient 
was  anaesthetized.  A  good-sized  hollow  needle  being  inserted  until  its  point  was  caught 
by  the  bone  at  the  site  mentioned,  a  drop  or  two  of  thick  pus  appeared  in  the  barrel 
of  the  hypodermic  syringe.  An  ample  incision  was  carried  along  the  outside  of  the 
triceps  tendon  down  to  the  bone,  whereupon  about  two  drachms  of  pus  escaped.  The 
periosteum  was  found  detached,  and,  being  deflected  by  an  elevator,  was  found  turgid 
and  deep  red,  except  at  the  place  of  detachment,  where  it  was  broken  down  and  green- 
ish-yellow. Profuse  oozing  took  place  from  the  exposed  bone  and  periosteum,  except- 
ing an  irregular  area  of  bone  covering  about  two  square  inches  just  above  the  posterior 
supratrochlear  fossa.  This  area  was  grayish  yellow,  and  did  not  bleed— in  short,  was 
necrosed.  The  wound  was  loosely  packed  with  carbolized  gauze,  and  was  enveloped 
in  a  moist  dressing.  The  patient  was  taken  to  her  home,  whence  she  was  removed  the 
following  day  to  a  hospital  by  her  relatives,  because  she  was  too  sick  to  be  taken  care 
of  at  home.  The  author  was  assured  that  her  mcessant  moaning  due  to  the  excruciat- 
ing pain  had  stopped  during  the  night  following  the  operation. 

Some  years  ago  the  author  saw  a  fatal  case  of  pelvic  osteomyelitis  in  consultation 
with  Dr.  H.  Kudlich.  The  patient  succumbed  to  the  violence  of  the  initial  symptoms 
— that  is,  to  acute  septicaemia.  The  seat  of  the  disease  was  the  sacrum  and  os  ihum  of 
a  very  muscular  man.  Very  intense  sciatica  and  liigh  fever  composed  the  initial  symp- 
toms. Enormous  oedema  of  the  left  thigh  and  inguinal  region  appeared  a  short  time 
before  death,  revealing  the  nature  of  the  aflfection,  which  until  then  had  baffled  attempts 
at  diagnosis.  The  pelvis  was  found  occupied  by  phlegmon  extending  below  Poupart's 
ligament.  The  probable  source  of  the  infection  was  a  recrudescent  suppurative  otitis 
media  of  old  standing. 

The  subject  is  full  of  difficulty  and  surrounded  by  many  drawbacks  in 
all  its  aspects.  The  impossibility  of  an  early  and  precise  diagnosis  as  to 
location,  the  depth,  and  often  the  inaccessibility  of  the  seat  of  the  disease, 
will  render  many  cases  impracticable  for  preventive  treatment. 

Secondary  abscesses  must  be  incised  and  drained  as  early  as  possible 
according  to  rules  above  given. 

(e)  Chronic  Suppuration  due  to  Bone  Necrosis.  Necrotomy. — The  most 
common  seats  of  acute  osteomyelitis  and  subsequent  bone  necrosis  are  the 
femur  and  tibia  near  the  knee-joint. 

This  fact  may  perhaps  be  explained  by  the  circumstance  that  the  upper 
epiphysis  of  the  tibia  and  the  lower  epiphysis  of  the  femur  ossify  much 
later  than  the  other  epiphyses  of  these  bones.      The  active  growth  and 


DIAGNOSIS  AND  TREATMENT   OF  PHLEGMON. 


209 


Ir^f 


Fig.  147. — Necrotomy  of  tibia.     Leg  placed  on  a  hard  cushion, 
playing  trom  the  right. 


Irrigator 


abundant  blood-supplj  near  the  knee-joint  seem  to  favor  the  importation 
and  deposition  there  of  active  micrococci  circulating  with  the  blood. 

]Slext  in  frequency  of  be- 
ing attacked  is  the  lower  jaw 
near  the  angle,  and  the  upper 
end  of  the  shaft  of  the  hu- 
merus. 

Note. — Very  likely  the  different 
arrangement  of  the  nutrient  vessels 
of  the  bones  of  the  upper  and  lower 
extremities  has  a  certain  influence  up- 
on the  frequency 
of  the  location  of 
osteomyelitis  near 
the  knee  and  shoul- 
der joints.  The 
nutrieiit  vessels  of 
the  femur  and  tibia 
diverge  from  the 
knee  -joint ;  those 
of  the  humerrus  and 
the  hones  of  the 
forea^rm  converge 
toivard  the  elbow* 
The  direct  and 
abundant  blood-supply  of  the  malleoli  and  the  coxal  end  of  the  femur  seems  to  cause  an 
earlier  consummation  of  the  osteogenetic  process  at  these  localities,  and  also  makes  them 
liable  to  a  form  of  infection  peculiar  to  the  infantile  period  of  life — namely,  tuberculosis. 
Tubercular  affections  of  the  ankle-  and  hip-joints  are  more  common  in  children  than  white  swell- 
ing of  the  knee.  During  adolescence,  when  the  physiological  fluxion  toward  the  knee-joint  pre- 
ponderates over  that  toward  the  ankle  and  hip,  the  tendency  to  osteomyelitis  near  and  tubercu- 
losis near  and  in  the  knee-joint  becomes  more  pronounced.  Similar  relations  seem  to  prevail  in 
reference  to  the  upper  extremity.  During  infancy  white  swelling  of  the  elbow  is  more  common 
than  that  of  the  shoulder  and  wrist-joints;  in  adolescence  the  upper  end  of  the  humerus  is  the 
common  seat  of  acute  osteomyelitis  ;  in  adults  the  shoulder  and  wrist  are  more  frequently 
attacked  by  tuberculosis  and  osteomyelitis. 

Whenever  an  attack  of  osteomyelitis  terminates  in  the  formation  of  an 
abscess  and  the  establishment  of  one  or  more  fistulse,  the  acute  features  of 
the  initial  stages  of  the  disorder  disappear.  The  abundant  discharge  of  pus 
is  followed  for  a  while  by  a  gradual  decrease  of  secretion,  which  again  in- 
creases as  the  separation  of  the  sequestrum  becomes  more  and  more  com- 
plete. This  is  explained  by  the  fact  that,  as  the  dead  bone  becomes  gradu- 
ally detached,  the  pus-generating  surface  of  the  cavity  containing  the 
sequestrum  becomes  proportionately  larger.  In  the  mean  time  new  osseous 
substance  is  thrown  out  by  those  portions  of  the  adjacent  bone  and  peri- 
osteum which  were  not  destroyed  by  suppuration,  and  thus  a  more  or  less 
perfect  involucrum  is  formed  around  the  sequestrum.  After  complete  de- 
tachment of  the  sequestrum,  suppuration  is  generally  profuse. 


Hyrtl,  "Descriptive  Anatomic,"  18Y0,  p.  209. 


210 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


Fig.  148. — Diagram  of  a  transverse  section, 
showing  relations  of  sequestrum,  involu- 
crum,  fistula,  and  skin. 


If  the  affection  is  extensive  and  no  spontaneous  or  artificial  relief  is 
vouchsafed  for  a  long  period,  a  deep  deterioration  of  the  general  health  will 

follow,  characterized  by  emaciation, 
anaemia,  albuminuria,  and  in  extreme 
cases  by  amyloid  degeneration  of  the 
liver  and  kidneys. 

The  diagnosis  of  the  presence  of 
a  sequestrum  can  be  made  by  noting' 
the  diffuse  thickening  of  the  affected 
bone,  the  profuse  secretion  from  one 
or  more  fistulae,  and  by  direct  prob- 
ing. If  the  direction  of  the  sinuses 
be  straight,  the  silver  probe  will  strike 
bare  and  roughened  bone-surface.  The  latter  symptom,  however  desirable 
for  the  establishment  of  a  positive  diagnosis,  is  not  absolutely  necessary  to 
it.  Indeed,  the  cases  are  quite 
common  where  tortuous  chan- 
nels prevent  direct  probing. 

Detachment  of  the  seques- 
trum is  indicated  by  its  mo- 
bility under  the  pressure  of  the 
probe-point,  or,  when  probing 
is  impracticable,  by  the  long 
duration  of  the  trouble  and 
the  increasing  or  profuse  dis- 
charge. 

Wlien  to  Operate. — It  may 
be  laid  down  as  a  general  rule 

that  the  best  time  to  perform  sequestrotomy  is  after  complete  detachment 
of  the  dead  bone,  which  can  be  ascertained  either  by  probing  or  by  the 
general  aspects  of  the  case.     Recognition  of  the  necrosed  parts  and  their 

complete  removal 
are  then  easy,  and 
will  be  followed  by 
a  rapid  cure.  This 
rule,  however,  ad- 
mits of  important 
exceptions. 

Note.  —  Extensive 
necroses  of  the  lower 
jaw  are  frequently  ac- 
companied by  a  profuse 
discharge  of  fetid  pus 
into  the  oral  cavity. 
This  and  the  inability 
to  masticate  food,  do  frequently  render  early  relief  by  operation  very  desirable.  The  objection 
that  to  perform  a  complete  operation  will  necessitate  the  sacrifice  of  healthy  bone  is  not  tenable. 


Fig.  149. — Xeuber's  niethod.  Top  of  involucrum  re- 
moved, skin-flaps  turned  into  the  bottom  of  the 
bone-cavit\^ 


Fig.  150. — Schede's  method.     Diagram  showing  relations  of  organ- 
izing blood-clot. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  211 

as  it  may  be  urged  that  even  an  incomplete  operation,  if  it  only  accomplish  the  removal  of  the 
greatest  portion  of  the  sequestrum,  will  be  followed  by  a  decided  improvement  of  the  patient's 
condition.  After  a  while,  a  secondary  operation  can  be  done  under  more  favorable  circumstances. 
Similar  considerations  may  also  indicate  an  early  sequestrotomy  in  other  regions. 

Neckotomy. — Artificial  ansemia  by  Esmarch's  band  and  antisepsis  have 
marked  important  changes  in  the  technique  of  sequestrotomy.  Control  of 
the  hgemorrhage,  and  the  possibility  of  healing  even  the  largest  sequestrot- 
omy wounds  without  suppuration,  justify  a  deliberate  search  after  detached 
foci  containing  sequestra  by  thorough  exposure  of  the  interior  of  the 
affected  bones.  Long  incisions  and  a  free  use  of  mallet  and  chisel  are 
proper.  A  compressive  antiseptic  dressing  will  insure  against  secondary 
hmmorrhage.  The  formation  and  maintenance  of  a  moist  blood-clot  in  the 
wound  will  bring  about  rapid  filling  up  of  the  cavity  by  new-formed  bone, 
and  will  terminate  in  firm  and  speedy  cicatrization. 

The  introduction  of  the  use  of  Esmarch's  band  has  deprived  extensive 
necrotomies  of  their  chief  danger — profuse  haemorrhage.  The  danger  of 
septic  disturbances  following  necrotomy  was  slight  even  before  the  adoption 
of  the  antiseptic  method,  as  the  densely  infiltrated  state  of  the  adjoining 
tissues  made  absorption  of  septic  matter  from  the  wound  difficult,  and  their 
rigidity  rendered  efficient  drainage  very  easy.  The  chief  advantage  of  the 
antiseptic  method  is  to  be  sought  in  the  possibility  of  effecting  a  cure  with- 
out the  long  course  of  suppuration  formerly  characteristic  of  the  healing  of 
these  cases. 

Neuber's  implantation  of  skin-flaps  was  the  first  step  in  the  direction  of 
accelerating  the  cure  of  necrotomy  wounds.  But  Scliede^s  methodical  and 
successful  utilization  of  the  protective  properties  of  the  moist  blood-clot  is 
the  simplest  and  most  perfect  means  to  the  end  in  view. 

The  indispensable  conditions  for  a  successful  employment  of  Schede's 
method  are  laid  down  in  the  following  projjositions  : 

First.  Thorough  exposure  of  the  seat  of  the  disease  by  incision  and  by 
the  use  of  mallet  and  chisel. 

Secondly.  Complete  removal  of  the  whole  sequestrum,  or  all  the  seques- 
tra, and  of  the  entire  pyogenic  membrane  lining  the  cavities  and  sinuses, 
by  scooping  and  scrajjing  with  the  sharp  spoon. 

Thirdly.  Thorough  disinfection  of  all  the  nooks  and  crevices  of  the 
wound  by  a  vigorous  use  of  the  irrigator  and  corrosive-sublimate  lotion, 
and  by  wiping  it  out  with  a  clean  sponge. 

Note. — The  final  flushing  and  mopping  out  should  always  be  done  with  the  strongest  solution 
of  corrosive  sublimate  used  by  surgeons  (1 :  500).  Residua  of  this  strong  lotion  are  then  washed 
away  by  a  mild  solution  to  prevent  mercurial  poisoning. 

Fourthly.  The  formation  of  a  blood-clot  which  should  fill  up  the  wound 
to  the  level  of  the  skin,  and  its  preservation  from  putrefaction  and  exsicca- 
tion by  a  suitable  antiseptic  dressing  (page  10). 

Note. — Leaving  behind  the  smallest  spiculum  of  undetected  dead  bone,  or  a  shred  of  the 
pyogenic  membrane,  will  partially  or  totally  compromise  the  success  of  this  procedure,  and  no 
amount  of  irrigation  will  avert  suppuration.    Fulfillment  of  the  second  proposition  is  not  difficult 
29 


212  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

except  in  the  disseminated  form  of  necrosis,  where  a  number  of  small  foci,  each  containing  its 
sequestrum,  and  all  connected  by  more  or  less  narrow  and  tortuous  channels,  are  scattered  within 
a  wide  area  of  the  affected  bone.  But  even  these  difficulties  can  be  overcome  by  the  exercise  of 
circumspection  and  painstaking,  favored  by  artificial  anaemia,  which  renders  detection  of  dis- 
colored bone  and  the  entrance  to  bone  sinuses  comparatively  easy. 

What  Chisels  to  iise. — The  chisels  generally  sold  by  surgical  cutlers  have 
little  to  commend  them  for  efficient  and  rapid  work.  Their  shape  and  size 
are  unsuitable.  ''Albert  Buck's  warranted  chisels,"  as  sold  by  most  hard- 
ware dealers,  and  generally  used  by  carpenters  and  Joiners,  are  well  tem- 
pered and  excellent.  They  should  be  fastened  to  an  ordinary,  smooth, 
wooden  handle,  without  indentations,  to  insure  the  possibility  of  perfect 
cleansing.  The  author  has  found  a  set  consisting  of  a  one-inch,  a  half- 
inch,  and  a  third-inch  chisel,  and  of  a  one-inch  and  a  half-inch  gouge,  to 
answer  every  purpose.  A  light  wooden  mallet,  perfectly  smooth,  its  head 
made  of  boxwood,  can  be  bought  in  any  house-furnishing  establishment,  and 
is  much  preferable  to  the  small  metal  mallets  of  the  instrument-makers. 

The  Modem  Manner  of  Performing  Necrotomy. — The  following  descrip- 
tion may  serve  as  an  elucidation  of  the  technique  of  a  sequestrotomy.  The 
parts  being  well  cleansed  with  soap  and  hot  water,  shaved,  and  disinfected 
by  mercuric  irrigation,  after  Esmarch's  band  is  applied,  an  incision  is  car- 
ried down  to  the  bone  over  or  near  the  fistulae.  The  length  of  the  external 
incision  should  be  proportionate  to  the  extent  of  bone  thickening.  The 
thickened  bone  should  always  be  attacked  where  it  is  most  superficial,  the 
site  of  the  incision  being  determined  rather  by  the  question  of  accessibility 
than  by  the  location  of  the  sinuses.  Where  the  bone  is  superficial,  as,  for 
instance,  the  tibia,  the  incision  may  be  at  once  carried  down  to  it.  "Where 
there  is  a  thick  mass  of  overlying  soft  tissues,  the  incision  should  be  gradual 
and  preparative,  and  all  cut  vessels  should  be  at  once  ligatured.  The  peri- 
osteum is  pried  up  on  both  sides  of  the  cut  with  an  elevator,  and,  where  it 
is  found  adherent  by  cicatricial  tissue,  is  cut  away,  until  the  entire  affected 
area  is  well  exposed.  Integument  and  periosteum  are  held  back  with  a  pair 
of  Volkmann's  retractors,  and  the  roof  of  the  cavity  containing  the  seques- 
trum is  chiseled  away.  This  can  be  done  very  rapidly  by  a  workmanlike 
use  of  the  mallet  and  chisel,  until  the  sequestrum  is  completely  exposed. 
This  being  done,  the  sequestrum  is  lifted  out  of  its  bed  with  a  pair  of  for- 
ceps. The  irregular  edges  of  the  cavity  are  next  smoothed  off,  overhanging 
parts  are  removed,  so  as  to  j^ermit  a  careful  and  thorough  ocular  examina- 
tion of  all  its  recesses.  Care  must  be  taken  not  to  leave  behind  any  dead 
bone.  The  sharp  spoon  should  be  used  in  vigorous  strokes  to  clear  away  all 
granulations  or  softened  osseous  tissue,  until  the  entire  wound-surface  pre- 
sents a  bleeding,  clean,  and  healthy  appearance.  Debris  and  shreds  of 
granulations  are  flushed  out  with  a  strong  irrigating  stream,  and,  to  make 
sure  that  no  detached  particles  of  tissue  are  left  behind,  the  cavity  should 
be  mopped  out  with  a  clean  sponge. 

Where  the  operator  is  not  certain  of  having  rendered  the  cavity  perfectly 
aseptic,  it  is  safest  not  to  apply  suture,  but  to  fill  it  with  a  loose  jDack- 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON. 


213 


ing  of  iodoformed  gauze,  and  to  swathe  the  limb  in  a  moist  compressive 
dressing.     The  dressing  should  be  ample,  and  should  contain  externally  a 

good  layer  of  elastic  material,  as,  for  instance,  ab- 

The  turns  of  the  roller  bandage 


sorbent  cotton. 


Fig.  151. 
Carpenters'  chisels. 


Fig.  152. 
Boxwood  mallet. 


Fig.  153. 
Elevator. 


Fig.  154. 

Volkmann's  sharp 

spoon. 


should  be  tight  and  close,  to  insure  a  sufficient  amount  of  elastic  compres- 
sion as  a  safeguard  against  secondary  haBmorrhage.  Ample  padding  will 
prevent  strangulation.  After  the  dressing  is  finished,  the  limb  is  held  ver- 
tically while  Esmarch's  band  is  removed. 

Note. — No  alarm  need  be  felt  if  the  finger-tips  or  toes  do  not  turn  pink  at  once.  A 
momentary  lowering  of  the  limb  will  immediately  produce  the  flush  indicative  of  the  hyperaemia 
due  to  paresis  of  the  vasomotor  nerves. 

Vertical  elevation  by  suspension  or  propping  up  should  be  maintained  for 
two  or  three  hours,  till  a  firm  clot  form  in  the  wound.  Should  some  blood 
permeate  the  dressings  and  appear  on  their  surface  a  short  time  after  the 


214 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


operation,  then  sufficient  pressure  was  not  employed.  Suitable-sized  com- 
presses of  iodoformed  and  sublimated  gauze  should  at  once  be  laid  upon 
the  blotch,  and  should  be  firmly  held  down  by  a  clean  elastic  or  flannel 
bandage.  This  additional  pressure  by  the  elastic  bandage  should  not  last 
more  than  an  hour. 

Case. — Herman  Albertin,  school-boy,  aged  nine.  Central  sequestrum  of  lower  end 
of  shaft  of  humerus  and  disseminated  necrosis  of  lower  epiphysis  due  to  acute  osteomye- 
litis. Necrotomy  performed  April  12,  1884,  at  German  Hospital,  under  chloroform. 
A  longitudinal  incision  five  inches  long,  commencing  at  the  upper  third  of  the  posterior 
aspect  of  the  left  humerus,  was  successively  carried  through  the  skin,  fascia,  and  triceps 
muscle,  until  the  musculo-spiral  nerve  was  exposed  and  freed  from  its  bed.  It  was 
taken  up  and  held  aside  by  a  blunt  hook.  The  periosteum  was  incised,  turned  aside, 
and  held  up  by  a  pair  of  Volkmann's  four-pronged  hooks.  The  posterior  face  of  the 
thickened  shaft  of  the  humerus  was  chiseled  away,  exposing  an  irregular-shaped 
central  sequestrum,  three  inches  long.  The  overlapping  parts  of  the  involucrum  were 
further  chiseled  off,  until  the  entire  sequestrum  could  be  easily  lifted  out  of  its  place. 
Two  small,  round  sequestra  were  removed  from  the  lower  epiphysis,  and  the  entire 
trough-shaped  cavity  was  carefully  scraped  out  with  a  sharp  spoon.  A  small  strip  of 
iodoformed  gauze  was  placed  into  the  most  dependent  part  of  the  bone  defect,  and  was 
brought  out  at  the  lower  angle  of  the  wound.  The  triceps,  fascia,  and  skin  were 
united  by  three  tiers  of  continuous  catgut  suture.  A  compressive  gauze  dressing  was 
bandaged  around  the  limb,  and  the  constricting  band  was  removed.  The  arm  was 
held  in  vertical  suspension  for  two  hours,  and  after  that  was  placed  in  the  semi-elevated 
posture  on  a  pillow.  The  temperature  remained  normal  throughout.  The  first  change 
of  dressings  was  made  April  26th,  a  fortnight  after  tlie  operation.  The  dressings  con- 
tained only  a  small  quantity  of  dried  blood.  The  fillet  of  gauze  being  removed,  a  new 
dressing  was  applied.  The  patient  was  discharged  from  the  hospital  April  30th,  with 
a  small,  superficially  granulating  wound  corresponding  to  the  place  of  drainage.     He 

returned  for  another  change  of  dressing  May  12th,  when 
A  B  tlie  wound  was  found  entirely  cicatrized  over. 

In  cases  where  the  surgeon  is  reasonably  sure 
of  having  produced  an  aseptic  wound,  either 
Neuber's  method  of  implantation  of  skin-flaps 
or,  what  is  better,  Schede's  treatment  can  be 
employed. 

Neubefs  Method  of  Implantation. — Neuber's 
idea  consists  in  the  endeavor  to  cover  up  with 
skin,  if  possible,  all  the  raw  surfaces  left  by  the 
operation.  Primary  union  is  the  object,  and  a 
minimum  of  uncovered  raw  tissues  is  left  to  heal 
by  granulation.  Longitudinal  hone  defects,  such 
as  are  caused  by  the  removal  of  a  necrosed  por- 
tion of  the  shaft,  are  partly  or  entirely  covered 
by  the  turning  in  of  tlie  edges  of  the  cutaneous  toound  till  they  meet  at  or 
near  the  bottom  of  the  groove  in  the  bone  (Fig.  149).  It  is  necessary  for 
this  purpose  to  dissect  up  laterally  the  skin  on  both  sides  of  the  incision  to 
a  goodly  extent,  so  as  to  render  it  movable  and  easily  held  in  the  new  posi- 
tion.    One  or  more  wide  sutures  of  catgut  are  passed  through  the  skin  at 


t/ 


Fio.  155. — -Simon  Nathan's  case. 

A,  Fenestra]   defect  of  tibia. 

B,  Bridge  removed. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON. 


215 


the  points  of  reflection  (Fig.  149),  to  retain  the  flaps  in  position  ;  and,  where 
this  is  not  sufiicient,  a  well-disinfected  nail  is  driven  through  the  edge  of 
the  flap  into  the  bone.  The  groove  thus  formed  is  loosely  packed  with 
strips  of  iodoform  gauze,  and  the  limb  is  incased  in  an  aseptic  dressing. 

Note. — Nails  are  disinfected  either  by  boiling  in  water 
or  by  being  passed  through  an  alcohol-flame  till  they  as- 
sume a  dull-red  heat.  After  this  they  are  dropped  into 
the  vessel  holding  carbolic  lotion  and  the  instruments. 

Case  I. — Simon  Nathau,  clerk,  aged  nineteen, 
admitted  to  the  German  Hospital  April  18,  1886. 
Had  been  operated  on  three  years  ago  for  necrosis 
of  tibia  by  Prof.  Schonborn,  of  Konigsberg.  A  fist- 
ula remained  on  the  anterior  aspect  of  the  leg,  that 
closed  up  and  broke  open  several  times  every  year. 
The  probe  detected  exposed  but  smooth  bone.  April 
22d. — The  patient  was  antesthetized  and  the  tibia 
was  exposed.  It  was  found  that  the  sinus  led  into  an 
oblong  defect  (Fig.  155)  of  the  shaft,  through  which 
the  probe  could  be  passed,  so  as  to  be  clearly  felt 
beneath  the  soft  tissues  of  the  calf.  The  length  of 
this  defect  was  a  little  more  than  an  inch,  its  width 
half  an  inch,  and  its  walls  were  formed  by  very  hard 
condensed  bone.  Apparently  the  sclerosed  condition 
of  this  bone  and  its  scanty  blood-supply  was  the  cause  of  the  frequent  ulceration  of 
the  deciduous  granulations  forming  within  the  track.  The  bridge  of  sclerosed  bone, 
together  with  the  adjacent  condensed  parts  of  the  shaft,  were  removed  by  mallet 
and  chisel ;  the  edges  of  the  cutaneous  wound  were  dissected  up  sufficiently  to  admit 
of  an  easy  adjustment  within  the  gap  between  the  tibia  and  fibula  (Fig.  156).  Two 
stout  catgut  sutures  were  passed  through  both  edges  of  the  skin-wound,  and  were 
brought  out  by  a  Peaslee's  needle  on  the  imder  side  of  the  calf,  where  they  were  firmly 


Fig.  156. — Simon  Nathan's  case. 
Implantation  of  cutaneous  edges 
into  the  defect  by  transfixing 
catgut  suture. 


Fig.  157. — Neuber's  method.     Frank  Nagengast's  case.     Implantation  of  triangular  flap  into  the 

defect  of  "the  head  of  tibia. 


knotted  over  a  piece  of  stout  drainage-tube.  Thus  the  edges  of  the  skin-flaps  were 
well  drawn  into  the  bottom  of  the  defect.  To  somewhat  relieve  the  pressure  by  the 
drainage-tube  upon  the  skin  of  the  calf,  a  nail  was  driven  through  one  of  the  flaps  into 
the  tibia,  and  the  leg  was  dressed  antiseptically.  Slight  elevations  of  the  temperature 
without  general  or  local  discomfort  were  observed  on  the  two  successive  days,  after 
which  the  normal  standard  remained  unchanged.     The  dressings  were  removed  May 


216 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


9th,  and  the  skin-flaps  were  found  firmly  adherent  in  their  new  position.  Some  cutane- 
ous ulceration  of  the  skin  on  the  calf  had  taken  place.  The  nail  was  removed.  The 
patient  was  discharged  cured  June  1st. 

XoTE. — A  sclerosed  and  ill-nourished  state  of  the  involucrum  will  often  lead  to  a  repeated 
breakdown  of  the  granulations  lining  an  old  sinus.  Stimulating  injections  will  sometimes  effect 
a  cure,  but  in  rebellious  cases  success  can  be  had  only  from  a  thorough  removal  of  the  condensed 
portions  of  the  bone  and  sinus. 

Case  II. — Frank  Nagengast,  aged  eight,  a  very  anfemic  boy.  Necrotomy  of  tibia, 
November  2,  1885,  at  Mount  Sinai  Hospital.     Extraction  of  a  large  central  sequestrum 


Fig.  158.— Diagram  illustrating  Schede's  method  applied  to  a  case  like  that  of  Frank  Nagengast. 

comprising  the  entire  thickness  of  the  upper  half  of  the  shaft,  a  narrow  extension 
reaching  down  to  the  lower  epiphysis.  Three  small  sequestra,  together  with  a  lot  of 
softened  granular  cancellous  tissue,  were  removed  from  the  head  of  the  tibia.  The 
remaining  posterior  portion  of  the  involucrum  was  so  slender  and  brittle  that  it  broke 

into  several  fragments  during  the 
operation.  Lateral  implantation 
of  the  skin  by  means  of  transfix- 
ing sutures  by  Peaslee's  needle. 
Antiseptic  dressing  and  a  lateral 
splint.  First  change  of  dressings 
November  23d.  Healing  of  the 
wound  by  adhesion  correspond- 
ing to  the  shaft.  Sinuses  lead- 
ing into  narrow  cavity  in  lower 
portion  of  tibia,  and  a  larger 
cavity  in  the  head  of  the  bone. 
Fractures  united  with  some  sag- 
ging of  tibia  downward.  De- 
cemher  17th. — Bloody  reinfrac- 
tion  of  tibia  ;  scraping  of  upper 
and  lower  cavities.  January  10, 
1886.— Lower  sinus  closed;  up- 
per cavity  shows  no  tendency  to  heal.  February  22,  1886. —  Osteoplastic  closure  of 
cavity  in  head  of  tibia  accordirig  to  Neuber.  A  triangular  skin-flap,  containing  the 
insertion  of  the  quadriceps  tendon  and  the  periosteum,  was  raised  from  the  anterior 
aspect  of  the  tibia.     The  remaining  roof  of  the  cavity  was  removed  by  mallet  and 


Fig.  159. — Frank  Nagengast's  case,  a,  Triangular  skin- 
flap.  B,  Skin- flap  turned  into  the  cavity ;  the  dark 
space  to  heal  by  granulation,  c.  View  of  necrotomy 
wound  treated  according  to  Schede's  method. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON. 


217 


chisel.  Previous  to  this  the  capsule  of  the  knee-joint  was  carefuUy  exposed  to  avoid 
entering  the  joint.  The  granular  lining  of  the  cavity  was  gouged  away,  and  only  a 
shell,  consisting  of  the  articular  surface  and  the  posterior 
portion  of  the  head  of  the  tibia,  remained  intact.  The  tri- 
angular skin-flap  was  turned  down  into  the  bottom  of  this 
cavity,  and  there  attached  by  a  nail  (Figs.  157-161).  The 
remaining  uncovered  Y-shaped  portion  of  the  wound  was 
left  to  granulate.  Under  an  antiseptic  dressing  firm  union 
of  the  flap  to  the  underlying  bone  took  place,  and  the  granu- 
lating part  of  the  wound  was  firmly  cicatrized  over  by  the 
middle  of  April. 

ScTiecWs  Method  (Fig.  162). — Schede's  plan  has 
the  great  advantage  over  Neuber's  method  that  it 
can  be  employed  successfully  under  the  most  vary- 
ing conditions.  Its  simplicity  and  independence  of 
the  presence  or  absence  of  a  sufficient  covering  hy  skin 
commend  it  to  the  attention  of  the  surgeon.  The 
author  found  Neuber's  plan  inadequate  where  much 
integument  had  been  lost,  and  was  replaced  by  an 
extensive  cicatrix. 


Case  I, — Frank  Hyman,  aged  twelve,  received,  in  May, 
1886,  a  blow  on  the  left  tibia,  after  which  central  osteomye- 
litis developed.  August  9th. — Necrotomy.  Two  large  se- 
questra were  removed  from  the  upper  half  of  the  shaft, 
requiring  three  separate  parallel  incisions  for  their  extraction, 
carefully  evacuated  of  all  granulations,  and  disinfected  with  a  1 

rosive  sublimate 


Fig.  160. — Anterior  view 
of  Frank  ISIagengast's  leg 
after  completed  cure. 


The  wound  was  very 
1,000  solution- of  cor- 
Simple  suture  of  the  cutaneous 
incisions;  a  small  drainage-tube  was  placed  into 
the  upper  angle  of  the  longest  incision.  All  the 
incisions  were  covered  with  strips  of  disinfected 
rubber  tissue,  and  the  limb  was  dressed  with  sub- 
limated gauze.  The  first  dressing  remained  un- 
changed for  four  weeks,  when  only  a  shallow  fist- 
ula remained  at  the  place  where  the  drainage-tube 
had  lain.  This  was  scraped,  and  it  promptly  healed. 

The  large  cavity  became  filled  with  a 
blood-clot,  which  organized  without  sup- 
puration. 

The  treatment  of  the  osteomyelitic  pro- 
cesses of  the  femur  and  their  sequelae,  nota- 
bly of  necrosis,  presents  peculiar  difficulties 
of  technique  mainly  due  to  the  deep  site  of 
the  bone.  Long  incisions  are  usually  indis- 
pensable, access  to  the  remote  portions  of 
the  bone  is  difficult,  and  the  necessary  injury 
to  many  muscular  branches  of  the  femoral  artery,  and  the  difficulty  of  effect- 
ive compression  of  the  muscular  masses,  render  the  question  of  after-hsm- 
orrhage  rather  serious.    It  is,  therefore,  advisable  not  to  deplete  the  limb  by 


Fig. 


161. — Lateral  view  i 
Nagengast's  leg. 


if  Frank 


218 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


an  elastic  bandage  of  all  its  blood  before  applying  Esmarch's  constriction. 
Each  cut  vessel  will  then  pour  out  a  small  quantity 
^m^.         ■  ■     ^^  blood,   and   can   be   readily  seen  and   deligated. 
J^^^  The  safest  approach  to  the  hone  is  from  the  external 

IgSi  ^  If-  as^ject,  preferably  above,  or  below  the  ham-strings. 

On  the  inner  side,  Himter^s  canal  requires  careful 
attention  on  account  of  the  femoral  artery.  The 
sequestrum  is  generally  located  near  the  posterior 
aspect  of  the  lower  end  of  the  shaft.  Should  it  even 
occur  that  the  popliteal  abscess  perforate  on  the  in- 
ner aspect  of  the  thigh,  exposure  of  the  sequestrum 
from  the  external  side  will  be  safer  and  more  easy. 
By  the  free  use  of  the  chisel  and  mallet,  sufficient 
access  can  be  gained  to  remove  the  sequestrum. 
Even  the  most  expert  operator  will  occasionally  fail 
to  find  a  small  sequestrum,  or  will  not  succeed  in 
its  entire  removal.  The  eventual  necessity  of  a  repe- 
tition of  the  operation  should  be  pointed  out  from 
the  outset  to  the  patient. 

Inferior  Maxilla. — As  a  rule,  osteomyelitic  foci 
of  tiie  lower  jaw  communicate  with  the  oral  cavity. 
This  makes  the  preservation  of  the  aseptic  condition 
of  the  wound  rather  difficult,  and  sometimes,  notably 
in  the  presence  of  a  neglected  and  foul  set  of  teeth, 
an  impossibility.  Where  the  process  is  extensive,  an 
external  incision  is  preferable,  as  it  lessens  the  dan- 
ger of  the  entrance  of  blood  into  the  respiratory  tract, 
and  facilitates  complete  and  clean  work. 


Tig.  162. — Illustrating  successive  steps  of  Schede's  dressing,  a,  Necrotomy  wound,  b,  Protect- 
ive, c,  lodotbrmed  gauze,  d,  Sublimate  gauze,  e,  Complete  dressing.  (Case  of  Samuel 
Krongoid.     Photographs  taken  ten  days  after  operation,  j 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  219 

Case. — I.  Eckert,  tailor,  aged  twenty-three,  contracted  traumatic  acute  osteomye- 
litis of  the  horizontal  ramus  of  the  left  side  of  the  lower  jaw,  after  the  extraction  of  a 
carious  tooth,  done  Xovember  2,  1886.  The  intense  pain  of  the  beginning  was  relieved 
by  a  spontaneous  discharge  of  pus  into  the  oral  cavity.  The  author  saw  the  patient 
November  23d,  when  the  thickening  of  the  jaw,  the  profuse  secretion,  and  direct  prob- 
ing put  the  presence  of  a  sequestrum  beyond  doubt.  Sequestrotomy  performed  Xovem- 
her  Soth.  The  mouth  had  been  prepared  for  a  day  or  two  by  frequent  rinsings  with 
salt  water ;  the  face  had  been  shaved.  The  back  of  the  anaesthetized  patient's  head 
was  rested  on  a  low,  hard  roll  made  of  a  blanket.  The  hair  was  wrapped  up  in  a  hood 
made  of  a  towel  dipped  in  corrosive  sublimate,  the  chest  protected  by  another  wet 
towel.  The  skin  of  the  jaw  was  well  soaped  and  rubbed  off  with  mercuric  lotion. 
Then  an  incision  two  inches  and  a  half  in  length  was  made  along  the  lower  edge  of  the 
horizontal  ramus.  The  facial  artery  was  exposed,  separated,  secured  by  two  pairs  of 
artery  forceps,  cut  through  between,  and  doubly  deligated.  The  periosteum  was 
incised  to  the  entire  length  of  the  external  cut,  and  was  reflected  upward  with  an  ele- 
vator. Before  opening  into  the  oral  cavity,  a  sponge  held  by  a  long  sponge-holder 
was  thrust  into  the  mouth  to  the  vicinity  of  the  fistula,  to  receive  any  blood  that  might 
escape  that  way.  An  oblong  quadrangle  of  the  external  lamella  of  the  alveolar  process 
and  body  of  the  ramus  was  chiseled  away,  exposing  a  cavity  containing  three  sequestra 
and  amass  of  ulcerating  fetid  granulations.  The  cavity  was  carefully  scraped  out  by 
the  sharp  spoon,  irrigated  with  corrosive  sublimate,  the  soiled  sponge  in  the  mouth 
having  first  been  substituted  by  a  clean  one.  The  opening  freely  communicating  with 
the  oral  cavity  was  plugged  with  a  strip  of  iodoformed  gauze,  that  reached  just  within 
the  focus ;  the  external  wound  was  closed  by  a  number  of  catgut  stitches,  a  short  drain- 
age-tube being  first  placed  in  its  posterior  angle.  December  ^(Z.— First  change  of  dress- 
ings. No  reaction ;  no  fever.  External  wound  was  found  closed,  the  drainage-tube 
was  shortened,  and  was  found  still  containing  a  dark-red  blood-clot.  The  iodoform  plug 
was  left  undisturbed,  and  was  removed  by  the  patient's  family  attendant  at  the  end  of 
the  second  week.     Discharge  was  scanty  throughout.     Patient  cured  December  20th. 

Bone  Abscess. — Circumscribed  acute  osteomyelitis  of  minor  intensity, 
caused  very  likely  by  infection  with  a  very  limited  number  of  micrococci 
deposited  in  the  medullary  substance  from  the  blood,  does  not  have  a  pro- 
nounced tendency  to  induce  massive  necrosis.  Breaking  down  and  emul- 
sification  of  the  affected  parts  are  tardy,  and  thus  opportunity  is  given 
to  the  surrounding  tissues  for  throwing  up  around  the  focus  a  protective 
wall  of  granulations.  The  extension  of  the  abscess  is  slow,  and  the  local 
as  well  as  general  disturbance  effected  by  it  is  of  a  chronic  character. 
Nightly  exacerbations  of  fever,  with  occasional  chills  and  sweats,  and  local- 
ized, deej)-seated  pain  of  a  throbbing  nature,  gradual  hypertrophy  of  the 
bone,  with  atrophy  of  the  pertinent  muscles,  trophic  changes  of  the  skin, 
as  glossiness  and  local  sweats,  and  increasing  emaciation,  are  the  character- 
istic symptoms  of  the  affection,  which  extends  over  months  and  even  years. 
The  marked  thickening  of  the  bone,  the  spontaneous  local  pain,  augmented 
by  pressure  on  percussion,  and  the  absence  of  fistula  are  mainly  to  be  con- 
sidered as  to  diagnosis.  Therapy  consists  in  doing  what  is  to  be  done  with 
all  abscesses — evacuation  and  eventually  drainage. 

The  consiDicuous  thickening  of  the  bone  serves  as  a  convenient  guide  to 
the  purulent  focus.  After  the  application  of  Esmarch's  constrictor,  a  free 
30 


220 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


incision,  made  according  to  the  rules  described  in  the  paragraph  on  necroto- 
my, exposes  the  bone,  the  surface  of  which  is  generally  found  covered  with 
osteophytic  excrescences,  that  somewhat  impede  the  raising  up  of  the  peri- 
osteum. All  the  soft  parts  being  held  away  by  sharp  retractors,  the  thick 
layer  of  new-formed  bone  is  pared  off  with  tlie  chisel,  layer  by  layer,  until 
the  cavity  containing  pus  is  exposed.  Sometimes  a  number  of  discrete  or 
communicating  foci  are  pi'esent,  and  the  surgeon  must  make  sure  of  not 
overlooking  any  of  them.  It  is  best,  accordingly,  to  expose  the  medullary 
space  throughout  the  entire  extent  of  the  thickening.  By  entirely  removing 
the  roof  of  the  cavity,  it  is  converted  into  a  more  or  less  shallow  trough, 
all  parts  of  which  are  exposed  to  ocular  inspection.  The  smooth  pyogenic 
membrane  lining  the  abscess  is  carefully  removed  to  its  last  shred  by  vigor- 
ous scraping  and  gouging  with  the  sharp  spoon,  and  by  subsequent  irriga- 
tion. A  final  flushing  of  the  wound  with  a  strong  (1  :  500)  solution  of 
corrosive  sublimate  will  make  sure  of  the  destruction  of  all  lingering  germs. 
The  wound  is  sutured  and  dressed  according  to  Schede's  plan,  and,  if  the 
removal  of  all  diseased  tissues  and  infectious  secretions  was  thorough,  rapid 
and  uninterrupted  healing  under  the  blood-clot  will  take  place. 

Case  I. — RichcarJ  Boss,  metal-worker,  aged  thirty-eight.  Chronic  painful  thick- 
ening of  the  shaft  of  the  humerus  of  two  years'  standing.  Glossy  skin,  atrophy  of  the 
muscles  of  the  arm  and  forearm,  formication,  and  hyperidrosis,  together  with  paretic 
symptoms  affecting 
principally  the  mus- 
culo -  spiral  nerve. 
Nightly  exacerba- 
tions of  local  pain 
and  hectic  emacia- 
tion. Fehruary  2, 
1887.— At  the  Ger- 
man Hospital,  expos- 
ure by  chisel  and 
mallet  of  a  bone  ab- 


FiQ.  163.— Exposure  of  thickened  humerus  containinj?  a  oentral  bone  abscess.  Elastic  constrictor 
tied  above  the  acromion,  and  thence  passed  around  thorax  into  the  opposite  armpit,  where 
it  is  secured  by  another  ligature. 


scess  occupying  the  middle  and  upper  part  of  the  medullary  cavity  of  the  left  hume- 
rus. Schede's  method  of  dressing  the  wound.  February  17th. — First  change  of  dress- 
ings.    Wound  united  by  the  first  intention.      Two  superficial  drainage-tubes  were 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON. 


221 


removed.  March  6th. — 
Patient  discharged  per- 
fectly cured  with  im- 
proving function  of  the 
extremity.  (Figs,  163, 
164,  and  165.) 

Case  II.  —  Samuel 
Krongold,  school  -  boy, 
aged  twelve,  had  had, 
several  years  ago,  com- 
pound dislocation  and 
acute  suppuration  of  the 
left  elbow-joint,  compli- 
cated with  acute  osteo- 
myelitis of  the  lower 
epiphysis  of  the  hume- 
rus, in  consequence  of 
which  several  sequestra 
had  to  be  removed  by  the 
author.  Three  months 
ago  a  painful  thickening 
of  the  shaft  of  the  hu- 
merus appeared,  causing 
marked  deterioration  of 
the  boy's  health.  February  18,  1887. — At  the  German  Hospital,  a  central  bone  abscess 
occupying  the  middle  portion  of  the  meduUary  space  of  the  humerus  was  exposed  and 
evacuated,  and  was  treated  by  Schede's  method.  February  26th. — The  first  change  of 
dressings  took  place,  and  the  entire  wound  was  found  healed  with  the  exception  of 
the  slit  left  open  for  drainage  at  the  lower  angle  of  the  wound,  which  was  occluded  by  a 


Fig.  164. — Cavity  chiseled  open.     Its  contents  removed  with  the 
shai-p  bpoon.     (Eichard  Boss.) 


fresh  -  looking  blood  -  clot. 
March  6th.  —  Patient  dis- 
charged completely  cared. 
(Fig.  162.) 

The  remarkably  short 
and  complete  cure  of 
both  of  these  cases  is 
undoubtedly  to  be  at- 
tributed to  the  adoption  of  Schede's  plan.  Plugging  of  and  introducing 
drainage-tubes  or  any  foreign  substance  into  the  bone  cavity  are  done  away 


Fig.  165. — Eichard  Boss's  wound  treated  accordinsr  to 
Schede's  method.  Photograph  taken  February  i7th, 
fifteen  days  after  operation. 


222  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

with,  and  organization  of  the  massive  blood-clot  goes  on  uninterruptedly 
to  the  greatest  advantage. 

Conclusions. 

Prevention  of  infection  contains  the  spirit  and  aim  of  aseptic  surgery ; 
the  object  of  antiseptic  surgery  is  disinfection  and  the  conservatio7i  of 
infected  tissues.  The  first  object  is  attained  by  a  severe  discipline  of  clean- 
liness ;  the  second  by  the  still  more  severe  discipline  of  early  incisioiis  and 
adequate  drainage  and  disinfection. 

A  clear  comprehension  of  the  processes  determining  suppuration  must 
result  in  the  firm  conviction  that  an  early  and  free  incision  of  every  focus 
of  septic  inflammation  is  the  most  conservative  form  of  treatment.  It  pre- 
vents local  death  and  general  intoxication,  the  latter  only  too  often  the 
cause  of  general  death.  If  this  conviction  will  have  entered  into  the  "smc- 
cum  et  sanguinem  "  of  every  physician,  public  opinion  will  gradually  yield 
to  a  better  understanding  of  individual  and  the  public  interest. 

Note. — The  change  in  the  surgeon's  attitude  toward  the  employment  of  incisions  for  septic 
inflammative  processes  is  characterized  by  these  sentences  : 

Formerly,  topical  applications  were  the  main  reliance,  incision  only  a  last  and  extreme 
resort.      TTie  surgeon  had  to  show  cause  why  an  incision  should  be  ynade. 

At  present,  relief  from  tension  and  escape  of  the  noxious  substances  through  incision  and 
drainage  is  the  clear  indication  to  be  fulfilled.  The  surgeon  must  show  cause  why  an  iiicision 
should  not  be  made  in  the  presence  of  septic  inflammation. 

2.  Phlegmonous  Affections  of  some  Special  Regions, 
a.  Face.    Floor  of  the  Mouth.    Neck.    Temporal  and  Mastoid  Regions  : 

Anatomical  Arrangement  of  the  Connectire-Tmue  Planes  of  the  Neck. — Henke's 
classical  essay  is  the  best  guide  for  the  clear  comprehension  of  this  subject.  He  injected 
the  different  interspaces  of  a  cadaver  with  liquid  gelatin,  and  studied  the  manner  of 
its  extension  between  the  several  organs  by  exposing  the  congealed  masses,  and  examin- 
ing their  relations  in  situ.  The  chief  interspaces  of  the  neck  are  classified  by  Henke 
as  follows : 

1.  The  Capsule  of  the  Submaxillary  Salivary  Gland. — It  forms  a  completely  closed 
envelope  to  the  gland,  from  which  continuations  extend  to  the  superficial  and  deep 
cervical  fasciae. 

2.  '•'•  Precisceral  Interspace.'''' — The  connective-tissue  plane  or  interspace  situated 
between  the  prelaryngeal  group  of  longitudinal  muscles  (hyo-thyroids,  sterno-hyoids, 
and  sterno-thyroids)  anteriorly,  and  the  larynx,  thyroid  gland,  and  trachea  posteriorly. 
It  communicates  with  the  anterior  mediastinum.  Perforation  of  a  suppurating  thyroid 
gland  leads  to  invasion  of  this  space,  with  subsequent  compression  of  the  trachea. 
(Fig.  166,  0.) 

Case. — S.  C,  aged  seventeen.  The  patient  was  treated  by  Dr.  C.  Lellmann  for  typhoid  fever 
in  the  German  Hospital.  In  the  third  week  of  the  disease  severe  dyspnoea  developed,  with  a 
peculiar  wheezing  sound  accompanying  respiration.  On  examination,  a  diffuse  swelling  was 
noted  in  front  of  the  neck.  Incision  evacuated  an  abscess  communicating  with  the  interior  of 
the  thyroid  gland,  whence  perforation  must  have  taken  place.     Immediate  relief  followed. 

3.  '•'■  Retroviseeral  Interspace.''"' — The  interspace  between  the  pharynx  and  oesoph- 
agus in  front,  and  the  vertebral  column  behind.  It  communicates  with  the  posterior 
mediastinum.    (Fig.  166,  a.) 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON. 


223 


4.  '■'■Perivascular  Interspaced — The  interspace  containing  the  carotid  artery  and 
jugular  vein.  It  communicates  with  the  anterior  mediastinum  along  the  course  of  the 
large  vessels,  and  is  important  on  account  of  the  frequent  suppuration  of  the  group  of 
lymphatic  glands  sit- 
uated in  front  of, 
and  externally  to 
the  jugular  vein. 
Abscesses  of  this  in- 
terspace displace  the 
sterno-mastoid  mus- 
cle outward;  they 
extend  along  the 
vessels  downward, 
and,  left  to  them- 
selves, either  per- 
forate through  the 
"deep  and  the  super- 
ficial fasciae  and  the 
skin  near  the  clavi- 
cle, between  the  low- 
er end  of  the  sterno- 
mastoid  muscle  and 
the  trachea,  or  make 
their  way  along  the 
vessels  into  the  an- 
terior mediastinum. 
(Fig.  167.) 

5.  '■'■Intermuscu- 
lar Space.'''' — An  interspace  situated  at  their  crossing,  between  the  lower  third  of  the 
sterno-mastoid  and  the  omo-hyoid  muscles.     This  space  owes  its  origin  to  the  sliding 

of  these  contiguous  mus- 
cles upon  each  other,  and 
is  limited  posteriorly  by 
the  scaleni.  It  contains  a 
group  of  lymphatic  glands, 
seated  near  the  posterior 
edge  of  the  lower  third  of 
the  sterno-mastoid  muscle 
(supraclavicular  glands), 
and  communicates  inward 
and  upward  with  the 
retrovisceral  space,  and 
along  the  subclavian  ves- 
sels with  the  axillary  cav- 
ity. Supraclavicular  ab- 
scesses usually  extend  into 
the  arm-pit.     (Tig.  168.) 


{a)  Face.  —  The 
most  serious  form  of 
cutaneous  and  subcu- 


FiG.  166. — c,  Previsceral  space. 
Antero-posterior  section. 


L,  Eetrovisceral  interspace. 
(From  Henke.) 


STERNOTHYROID 
SUBCUTANIAN 


CAROTID 

JUGULAR 


Fig.  167.- 


-Perivascular  interspace. 
(From  Henke.) 


Transverse  section. 


224 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


Fig.  U 


. — Intermuscular  space.     Lateral  antero-posterior  section. 
(From  Henke.) 


taiieous  phlegmon  observed  on  the  face  is  the  carhimde.  It  is  characterized 
by  a  dense,  hard  swelling  of  conical  shape,  extending  far  into  the  subcu- 
taneous connective  tis- 
sue. It  has  a  dusky 
red  color,  and  its  apex 
IS  marked  by  one  or 
more  yellowish  discol- 
ored spots,  which  are 
surrounded  by  a  bluish 
halo.  Septic  thrombo- 
sis extending  through 
the  jugular  veins  into 
the  cranium  is  to  be 
feared  in  this  affec- 
tion. The  systemic  in- 
toxication is  generally 
very  intense,  high  fe- 
ver being  the  rule.  In 
some  of  the  worst  cases  the  intoxication  is  so  deep  as  to  cause  symptoms  of 
collapse,  with  low%  sometimes  even  subnormal,  temperatures. 

In  this  condition  an  early  and  most  energetic  treatment  is  urgently 
indicated,  and  is  almost  always  followed  by  elimination  of  the  infectious 
process. 

A  crucial  incision,  or,  in  extensive  cases,  a  number  of  parallel  incisions, 
carried  in  length  and  depth  beyond  the  indurated  area,  will  relieve  tension 
and  permit  the  escape  of  the  contents  of  many  smaller  or  larger  incarcerated 
foci.  The  incisions  should  be  packed  lightly  with  strips  of  iodoformed 
gauze.  In  cases  of  ancemia,  where  loss  of  blood  would  materially  increase 
the  danger,  tlie  actual  cautery  should  be  so  applied  as  to  convert  the  entire 
infected  area  into  a  dry  eschar.  This  or  the  incisions  should  be  enveloped 
in  a  moist  dressing,  which  has  to  be  renewed  according  to  the  amount  of 
secretions. 

Note. — The  following  bloodless  treatment  applied  by  Slesarewskij  in  forty-four  cases  of  car- 
buncle seems  to  deserve  trial,  as  it  yielded  very  good  results  in  his  hands  :  Inspissated  crusts  are 
first  removed,  then  the  diseased  surface  is  sprinkled  with  from  thirty  to  sixty  grains  of  corrosive- 
sublimate  powder.  The  dusky  halo  surrounding  the  center  of  the  sore  is  thickly  covered  with 
blue  ointment,  and  the  whole  is  enveloped  in  a  compress  soaked  in  carbolized  oil  (1  :  10),  fast- 
ened with  a  roller  bandage.  In  case  of  severe  pain,  an  ice-bag  is  placed  over  the  dressing.  The 
following  day,  corresponding  to  the  application  of  the  mercuric  salt,  a  gray,  very  dense  eschar 
will  be  visible,  which  will  separate  ten  days  later,  and  will  be  followed  by  rapid  healing. 
Slesarewskij  never  observed  mercuric  intoxication  during  or  after  the  application  of  this  method 
of  treatment.     ("  Centralblatt  fur  Chirurgie,"  1886,  p.  805.) 

Case. — The  author  lost,  of  a  considerable  number  of  cases  treated  by  incision,  only 
one  by  septic  phlebitis  of  the  right  lateral  sinus.  Tlie  patient,  a  middle-aged  cigar- 
raaker,  was  seen  in  consultation  with  Dr.  L.  Weiss,  and  an  enormous  carbuncle  occupy- 
ing the  riglit  side  of  the  upper  lip  and  cheek  was  found,  with  extensive  oedema  of  the 
eyelids  and  the  right  side  of  face  and  neck,  which  was  due  to  general  thrombosis  of 


DIAGNOSIS   AND  TREATMENT  OF  PHLEGMON. 


225 


\. 


the  pertinent  vein?.  The  patient  was  semi-comatose,  somewhat  cyanosed,  and  had  a 
poor  pulse.  He  had  obstinately  opposed  any  incisive  treatment  for  six  days,  and  the 
case  seemed  clearly  beyond  the  reach  of  surgical  skill.  The  incisions  caused  very  little 
haemorrhage,  as  most  of  the  divided  tissues  were  necrosed.  He  died  of  collapse  on  the 
seventh  day  of  his  illness. 

The  author  has  never  tried  any  of  the  "  maturing  "  forms  of  treatment 
in  this  affection,  and  would  unhesibatingly  declare  measures  which  are  apt 
to  stimulate  suppuration,  such  as  poulticing,  to  be  always  risky,  and  some- 
times positively  dangerous. 

(J)  Neck. — (a)  Fauces  and  Pharynx. — The  tonsils  and  the  connective 
tissue  in  which  they  lie  imbedded  are  the  most  favorite  site  of  superficial 
and  deep-seated  septic  processes.  DipMhei^ia  is  very  likely  a  microbial 
affection  due  to  the  colonization  of  micrococci  upon  the  surface  and  in  the 
follicles  of  tonsils,  that  are  in  a  state  of  catarrhal  or  scarlatinal  inflammation. 
It  is  characterized  by  superficial  or  deep-going  putrid  necrosis  of  the  affected 
tissues,  often  extending  to  the  pharynx,  larynx,  velum,  pillars,  and  the  nasal 
mucous  membrane,  and  is  generally  accompanied  by  a  serious  general  intoxi- 
cation. The  systemic  intoxication  is  most  prominent  when  parts  having 
an  abundant  supply  of  lymphatics,  as  the  pillars  of  the  fauces,  the  velum, 
pharynx,  and  nasal  mucous  membrane,  are  involved.  The  scantier  de- 
velopment of  the  tonsillar 
V-H  '!"^  •■'■     ^^  '  *"!     and  laryngeal  lymph-ves- 

sels seems  to  be  the  cause 
of  the  minor  intensity  of 
the  systemic  symptoms  ob- 
served in  affections  local- 
ized in  these  parts.  Char- 
acteristic intumescence  of 
the  deep  cervical  lymph- 
glands  is  a  regular  conse- 
quence of  the  affection  of 
the  first  group  of  localities;  it  is 
more  rarely  observed  in  purely 
tonsillar  or  laryngeal  diphtheria. 
An  invasion  is  apt  to  leave  be- 
hind a  certain  disposition  to  re- 
newed attacks,  which  is  perhaps 
due  to  the  fact  that  quiescent  spores  of  bacteria  remain  imbedded  in  the 
recesses  of  the  follicles,  to  develop  their  activity  whenever  a  new  catarrhal 
inflammation  and  exudative  process  prepares  the  ground  for  their  multi- 
plication. 

But,  on  the  other  hand,  frequent  attacks,  and  the  accompanying 
formation  of  cicatricial  tissue  within  the  textures  of  the  tonsils,  seem 
to  lead  to  a  certain  immunity  from  the  graver  forms  of  the  disease.  As 
a  rule,  persons  who  never  had  diphtheria  suffer  more  severely  than  those 
who  have  gone  through  many  attacks  ;    and  diphtheria   of   children  for- 


FiG.  169. — Bacteria  from  ease  of  vesical  diphtheria 
with  putrescence  (700  diameters).     (Koch.) 


226  RULES  OF  ASEPTIC  AND   ANTISEPTIC  SURGERY. 

merly  free  from  the  disease  is  a  much  more  serious  condition  than  the 
so-called  habitual  '•  follicular  tonsillitis."  While  a  first  attack  is  usu- 
ally, habitual  follicular  tonsillitis  is  rarely,  complicated  with  glandular 
enlargement. 

The  condition  of  things  here  is  comparable  to  that  which  was  mentioned 
as  the  ''habituation  of  the  hands  of  anatomists  to  septic  infection"  (see 
page  197,  Note  I).  The  disease  is  highly  contagious,  hence  isolation  of  the 
patient  is  imperative  wherever  possible. 

Aided  by  a  sustaining  and  stimulating  general  treatment,  the  disinfec- 
tion of  the  local  septic  state  should  be  most  energetically  pursued.  Accord- 
ing to  the  age  and  disposition  of  the  patient,  this  will  have  to  be  done  dif- 
ferently. In  small  children  of  a  good  disposition,  penciliugs  of  the  affected 
parts  with  milder  or  stronger  solutions  of  corrosive  sublimate  repeated  every 
hour,  and,  in  case  of  nasal  diphtheria,  hourly  syringing  of  the  interior  of 
the  nose,  should  be  practiced.  A  mixture  of  corrosive  sublimate  0*03, 
alcohol  25*00  (or  one-half  grain  to  the  ounce),  can  be  safely  used  for  pencil- 
ing the  tonsils  and  pharynx.  A  tepid  watery  solution  of  1:  5,000  for  syring- 
ing the  nasal  cavity  will  be  well  borne.  Care  must  be  taken  to  keep  the 
nostrils  well  anointed  with  vaseline  to  prevent  eczema,  and  never  to  use  a 
sharp,  long-beaked  syringe.  During  the  struggles  of  the  resisting  child  the 
mucous  membrane  is  easily  lacerated,  and  the  haemorrhage  and  certain  infec- 
tion of  the  part  thus  injured  are  not  indifferent  in  an  affection  where  the 
least  complication  may  suffice  to  fatally  determine  the  case.  The  safest 
manner  of  douching  the  nose  is  by  attaching  to  the  nozzle  of  the  syringe 
a  piece  (six  inches  in  length)  of  soft  rubber  tubing,  such  as  is  used  on 
infants'  feeding-bottles,  its  distal  end  being  first  provided  with  a  few  lat- 
eral holes  cut  into  it  with  scissors.  The  syringe  is  filled  with  the  warm 
lotion,  the  well-greased  flexible  tube  is  introduced  into  the  nostril  and 
pushed  back  until  it  is  felt  to  touch  the  posterior  pharyngeal  wall,  the 
child's  head  is  inclined  forward,  and  then  the  contents  of  the  syringe  are 
briskly  thrown  into  the  nasal  cavity.  The  immediate  reflex  closure  of 
the  larynx  and  isthmus  faucium  will  prevent  the  entrance  of  considerable 
quantities  of  the  lotion  into  these  organs,  and  the  energetic  stream  will 
aid  the  detachment  and  expulsion  of  crusts,  membrane,  and  liquid 
secretions.  On  account  of  the  swollen  condition  of  the  mucous  mem- 
brane, the  entrance  of  acrid  secretions  into  the  Eustachian  tubes  need  not 
be  feared. 

The  throats  of  larger  children  or  grown  j^ersons  can  be  cleansed  by  fre- 
quent gargling  with  a  tepid  solution  of  (1  :  5,000)  corrosive  sublimate,  con- 
taining one  teaspoonful  of  cooking  salt.  The  principal  weight  should  be 
laid  upon  a  frequent  application  of  the  gargle  and  a  stimulating,  nourish- 
ing, general  regime. 

Whenever  the  aspect  of  the  malady  is  very  threatening,  the  appli- 
cation of  the  galvano-cautery  to  the  affected  parts  may  be  advisable. 
It  is,  with  cocaine  anesthesia,  a  safe  and  rational  process.  That  only 
a  portion  of  the  patches  are  accessible,  some  of  them  being  beyond  the 


DIAGNOSIS  AND  TEEATMENT   OF  PHLEGMON. 


227 


surgeon's  reach  in  the  nasal  cayity,  is  no  ralid  reason  why  those  that  are 
amenable  to  this  yery  effectiye  mode  of  disinfection  should  not  thus  be 
treated. 

The  best  way  of  cauterizing  the  tonsils  and  pharynx  is  the  following 
one  : 

The  head  of  the  anaesthetized  iDatient  is  drawn  oyer  the  under j)added 
edge  of  the  table  until  it  assumes  the  dependent,  or  Eose's,  position  (Fig. 
170).  The  surgeon  introduces  a  bent  tongue-depressor,  or  the  bent  handle 
of  a  tablespoon,  well  back  into  the  fauces,  and  instructs  the  ansesthe- 
tizer  to  keep  the  tongue  out  of  the 
way  by  it.  This  will  expose  the 
pharynx  in  an  admirable  fashion  to 
permit  of  the  exact  and  thorough  ap- 
plication of  the  thermo-  or  galyano- 
cautery  to  the  patches  thus  exposed. 
If  the  disease  be  limited  to  visible 
parts  of  the  oral  cayity,  and  all  the 
patches  can  be  thus  treated,  a  rapid 
improyement  of  the  general  state  of 
intoxication  will,  as  a  rule,  at  once 
follow  the  procedure.  Where  only  a 
part  of  the  patches  is  thus  treated,  the 
improvement  will  not  be  as  complete. 

The  glandular  enlargement  also 
requires  attention,  and  should  be 
treated  as  was  explained  elsewhere. 

If  the  process  descend  to  the  larynx,  very  alarming  dyspnoea  will  grad- 
ually develop.  It  should  be  combated  with  external  hot  applications  to  the 
throat,  and  the  inhalation  of  moist,  warm  air  generated  in  the  sick-room. 
The  patient's  strength  should  be  carefully  husbanded  by  frequent  doses  of 
liquid  nourishment,  and  the  avoidance  of  unnecessary  excitement,  exposure, 
and,  most  of  all,  strong  emetics,  the  abuse  of  which  has  cost  many  a  child's 
life.  In  most  cases  the  membrane  will  get  detached  piecemeal,  or  will 
come  away  in  one  or  more  large  masses,  and  relief  will  follow,  perhaps  only 
to  be  succeeded  by  another  or  several  suffocative  attacks.  As  long  as  there  is 
no  lung  complication,  the  pulse  fairly  good,  intubation  offers  fair  chances  of 
success.  Where  the  patient's  strength  has  been  consumed  by  a  very  long, 
ceaseless  struggle  for  air,  or  the  depressing  use  of  emetics,  the  chances  are 
by  far  more  slender.  Yet  even  the  most  desperate  cases  sometimes  yield 
unexpectedly  good  results.  When  intubation  is  not  feasible,  tracheotomy 
has  to  be  performed. 

Preventive  Treatment  of  Tonsillitis. — The  tonsils  are  the  points  where 
the  first  patches  become  visible  in  most  cases,  and  whence  the  local  infec- 
tion extends  to  other  contiguous  parts.  After  frequent  attacks  of  tonsillitis, 
the  surface  of  the  tonsils  becomes  irregularly  indented  by  cicatricial  retrac- 
tion ;  the  tonsil  itself  is  enlarged,  and  often  yields  on  pressure  one  or  more 

31 


Fig.  170. — Rose's  position.     Head  dependent 
from  the  edge  of  the  operating  table. 


228  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

yellowish  plugs  of  a  very  fetid  cheesy  matter  which  were  contained  within 
the  follicles. 

Note.— Drs.  E.  Gruening  and  S.  Cohn  called  my  attention  to  this  fact,  which  I  have  repeat- 
edly verified. 

These  yellowish  masses  are,  as  shown  by  Gruening,  swarming  with  lep- 
tothrix  and  other  micro-organisms,  and  the  presence  of  these  is  undoubt- 
edly at  the  bottom  of  the  so-called  "disposition  "  to  catch  the  disease.  The 
reservoir  of  infecting  material  is  ever  there  ;  the  patient  carries  it  constantly 
with  him,  and  a  catarrhal  hyperaemia,  followed  by  some  infiltration  and 
epithelial  erosion,  is  all  that  is  needed  to  develop  a  new  attack  of  ''follic- 
ular tonsillitis,"  which  may  not  threaten  its  possessor  with  great  danger, 
but  is  just  as  contagious  to  others  as  any  case  of  diphtheria.  One  observa- 
tion like  the  following  Avill  carry  much  conviction. 

Two  children  of  the  same  family  had  attacks  of  sore  throat  one  after  the  other. 
The  first,  a  boy  four  years  old,  who  has  had  tonsillitis  a  number  of  times,  exhibited  the 
usual  symptoms  of  his  affection ;  the  second  one,  a  boy  about  a  year  old,  and  hitherto 
free  from  the  disease,  was  carried  into  the  sick-room  of  the  first  child  by  an  obstinate 
nurse,  and  came  down  the  next  day  with  very  alarming  systemic  symptoms,  high  fever, 
and  somnolence,  exhibiting  a  small  patch  on  his  left  tonsil.  The  first  boy  recovered  in 
about  four  days,  the  usual  length  of  his  attack  ;  by  the  time  that  he  was  well,  the  baby 
had  died  under  symptoms  of  most  acute  septicaemia.  A  petechial  rash,  commencing 
on  the  nates  and  feet,  extended  upward,  and  gradually  flecked  the  entire  skin.  The 
patch  on  the  tonsil  had  grown  and  others  had  developed,  the  somnolence  turned  into 
coma,  and  was  followed  by  death. 

The  wet-nurse  of  this  child  and  the  cook  of  the  family,  who  had  kissed  the  corpse, 
became  seriously  ill  with  diphtheria ;  especially  the  latter,  whose  condition  was  critical 
for  three  or  four  days.  At  the  same  time,  a  male  servant  and  two  more  members  of 
the  family  contracted  sore  throats  of  various  degrees  of  intensity,  and  the  house  had 
to  be  abandoned.  A  friend  and  his  wife  called  in  the  evening  shortly  after  the  child's 
death  to  pay  a  visit  of  condolence.  The  next  morning  one  of  their  children  was  down 
with  malignant  diphtheria,  and  died  in  a  day  or  two  of  septicaemia. 

Destroying  the  entire  surface  of  the  tonsil,  together  with  the  contents  of 
the  follicles  by  the  application  of  the  galvano-cautery,  would  seem  to  be 
rational,  and  has  been  found  a  safe  and  effective  measure  for  lessening  the 
disposition  to  renewed  attacks  of  diphtheria.  It  is  infinitely  safer  than  a 
bloody  ablation  of  the  tonsils,  as  the  dangers  of  haemorrhage  and  diphtheria 
of  the  wound-surface  are  thereby  avoided.  The  smooth,  dense  cicatrix  thus 
produced  offers  a  very  good  protection  against  new  infection. 

In  adults,  or  even  in  half-grown  children  amenable  to  control,  the  reduc- 
tion of  the  tonsil  can  be  gradually  accomplished  without  general  anaesthe- 
sia, the  procedure  extending  over  a  number  of  sittings.  The  throat  is  pen- 
cilled with  a  cocaine  solution  until  local  anaesthesia  is  produced ;  then  a  cold 
galvano-caustic  burner  is  introduced.  It  is  placed  against  the  part  to  be 
treated,  the  current  is  turned  on,  and  one  fourth  or  one  third  of  the  ton- 
sillar surface  is  thoroughly  seared.  For  an  hour  or  so,  small  pieces  of  ice 
should  be  swallowed  by  the  patient  to  allay  the  slight  pain.  The  sittings 
can  be  repeated  about  twice  a  week  or  oftener. 


DIAGNOSIS  AND  TEEATMENT  OF  PHLEGMON.  229 

Quincy  sore  throat  (peritonsillitis)  is  a  phlegmonous  process  established 
in  the  tonsil  itself,  or  in  the  loose  connective  tissue  in  which  it  is  imbedded. 
The  tonsil  is  found  enlarged,  projecting  into  the  pharynx,  and  displacing 
forward  the  anterior  pillar  and  velum.  Dysphagia  and  more  or  less  saliva- 
tion with  high  fever  are  regularly  present,  and  do  not  terminate  until 
thorough  evacuation  has  taken  place.  In  most  cases  confluence  of  a  number 
of  small  abscesses  and  simultaneous  evacuation  is  observed.  In  others, 
especially  when  the  tonsil  itself  is  the  seat  of  the  affection,  a  number  of 
abscesses  develop  and  open  one  after  another,  and  retard  recovery  for  a 
week  or  two.  No  local  treatment  short  of  incision  can  effect  a  substantial 
improvement,  and  the  different  gargling  mixtures  are  only  useful  in  clear- 
ing the  throat  and  mouth  of  the  foul,  sticky  slime  aggravating  the  patient's 
sufferings  by  exciting  very  painful  reflex  movements  at  deglutition.  Hot 
salt  water  (one  teaspoonful  to  a  quart,  about  6  : 1,000)  is  the  best,  as  it  is 
the  most  solvent  gargle,  and  can  be  easily  procured.  As  the  exact  location 
of  the  abscess  can  not  be  ascertained  easily  beforehand,  it  is  wise  to  wait 
with  the  incision  until  the  swelling  is  well  developed.  A  digital  examina- 
tion of  the  swollen  region  is  always  advisable,  as  it  is  not  rare  that  the  tip 
of  the  finger  detects  a  pitting  spot  at  which  incision  will  release  pus.  If 
pitting  can  not  be  detected,  an  examination  with  the  tip  of  a  silver  probe 
will  possibly  help  to  ascertain  the  most  painful  spot  corresponding  to  the 
focus  to  be  incised.  The  relative  distribution  of  the  swelling  may  also  serve 
as  a  guide  in  determining  the  seat  of  pus.  Acute  enlargement  of  the  tonsil 
itself  with  diffuse  oedema  of  the  pillars  and  palate  indicates  supjuiration 
withm  the  tonsil.  Displacement  of  the  relatively  normal  tonsil  inward  is  a 
sign  of  retro-tonsillar  suppuration.  A  combination  of  both  will  show  the 
worst  association  of  distressing  symptoms. 

Incising  Tonsillar  Abscess. — A  lancet-shaped  pointed  bistoury  is  pro- 
tected with  strips  of  adhesive  plaster  to  within  an  inch  of  its  point  (Fig. 
171),  the  tongue  is  depressed  with  the  left  index-finger,  while  the  right 
band  thrusts  the  knife  into  the  base  of  the  swelling  through  the  anterior 
pillar  at  the  point 

tero-posterior  di-     ^^^^^^=^=^"  '      kIlI^    -  — 

rection  should  be       ^^^-  '^'^^- — Lancet-shaped  bistoury  wrapped  up  in  adhesive  plaster  for 

incision  of  tonsillar  abscess. 

rigidly  adhered  to 

on  account  of  the  vicinity  of  the  carotid  artery.  If  the  first  puncture  be 
unsuccessful,  a  second  one  should  be  made  in  another  likely  place,  and,  as 
soon  as  pus  appears,  the  blade  should  be  turned  inward,  that  is,  toward  the 
median  line,  and  should  be  withdrawn,  dilating  the  incision  in  that  direc- 
tion. A  number  of  fibers  belonging  to  the  levator  palati  will  be  thus  divided, 
and  their  retraction  will  create  a  patent  orifice,  favorable  to  good  drainage. 
Retro-pTiaryngeal  phlegmon  is  a  comparatively  rare  suppuration  of  the 
retro-pharyngeal  connective  tissue,  due  to  septic  infection  of  the  glands 
normally  imbedded  in  it.     It  is  mostly  observed  in  small  children.     The 


230  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

symptoms  are  those  of  retro-pharyngeal  abscess  from  tuberculous  caries  of 
the  cervical  vertebrae,  but  its  appearance  is  much  more  rapid,  accompanied 
by  high  septic  fever  and  more  acute  local  distress,  causing  difficulty  of 
deglutition,  regurgitation  of  food  through  the  nostrils,  and  alarming 
dyspnoea.  The  most  characteristic  symptom  is  the  peculiarly  rigid  attitude- 
of  the  head,  whicli  is  erect,  and  thrown  back  to  a  certain  extent  at  the  same 
time.  The  voice  is  thick  and  guttural,  as  though  a  voluminous  foreign 
body  were  held  in  the  throat. 

In  some  cases  the  suppuration  extends  to  the  "intermuscular  space,"" 
and  causes  the  appearance  of  a  lateral  external  swelling  behind  the  sterno- 
mastoid  muscle.  The  transverse  diameter  of  the  neck  then  appears  widened. 
Inspection  of  the  pharynx  shows  that  the  posterior  pharyngeal  wall  is  dis- 
placed forward,  is  densely  infiltrated,  and  sometimes  fluctuating. 

Incision  should  be  done  through  the  oral  cavity  if  the  inflammation  is 
confined  to  the  retro-pharyngeal  region,  but  will  be  more  advantageous  if 
done  from  without  and  behind  the  sterno-mastoid  muscle  in  cases  where 
external  swelling  of  the  cervical  region  is  noticeable. 

In  the  first  case,  the  children  should  be  held  as  for  penciling  of  the 
throat,  and  the  person  having  charge  of  the  head  should  be  instructed  to 
throw  it  forward  at  a  given  signal,  so  as  to  favor  the  escape  of  pus  and 
blood  outward  from  the  oral  cavity,  and  prevent  its  entering  the  larynx. 

If  lateral  swellings  appear,  proper  incision  from  without  will  afford 
efficient  drainage,  and  at  the  same  time  will  help  to  avoid  the  dangers  accru- 
ing from  the  entrance  of  \n\s  into  the  larynx.^ 

The  manner  of  incision  is  best  illustrated  by  the  subjoined  cases. 

Of  a  large  number  of  cases  treated  at  the  German  Dispensary,  and  a  few 
seen  at  consultations  in  private  practice,  only  two  have  terminated  fatally, 
and  in  both  serious  haemorrhage  occurred  a  few  hours  after  the  incision. 

Case  I.— S.  P.,  aged  eighteen  months,  seen  May  17,  1883,  with  Dr.  L.  Weiss. 
Retro-pharyngeal  and  submaxillary  abscess  developed  during  the  florid  stage  of  a 
violent  scarlatina  with  diphtheria.  Dysphagia  and  dyspnoea.  Small  lateral  incision 
through  the  skin  and  fascia  parallel  to,  and  behind  the  posterior  margin  of  the  left 
sterno-mastoid  muscle.  Successful  search  for  pus  with  a  stout  hypodermic  needle,  carried 
inward  and  a  little  backward  toward  the  retro-pharyngeal  space.  Insinuation  of  a 
grooved  director  along  the  hollow  needle,  followed  up  by  the  introduction  of  a  small 
pair  of  dressing  forceps,  which  were  withdrawn  half  opened.  Escape  of  about  one 
and  a  half  ounce  of  pus  and  introduction  of  a  drainage-tube.  Two  hours  after  incision 
copious  secondary  hteraorrhage  set  ic,  and  rapidly  terminated  in  death.  Giving  away 
of  the  wall  of  a  sloughing  vessel  must  be  assumed  to  have  caused  this  issue. 

Case  II. — Henry  W.,  aged  four  and  a  half  months,  a  healthy  child,  developed, 
March  4,  1883,  fever  and  dysphagia,  due  to  the  presence  of  a  number  of  .small  abscesses 
situated  in  the  retro-pharyngeal  connective  tissue.  Several  of  these  were  incised  by 
Dr.  A.  Jacobi,  with  apparent  relief  of  short  duration.  New  foci  appearing,  the  incisions 
were  repeated  March  6tli  and  8th.  March  9th. — Dysphagia  became  complete  and 
dyspnoea  alarming.  Although  the  incisions  through  the  retro-pharyngeal  space  con- 
tinued to  bleed,  increasing  the  danger  by  the  addition  of  haemorrhage  to  the  other 
symptoms,  the  extension  of  the  process  to  the  connective-tissue  plane  of  the  large 


DIAGNOSIS  AND  TEEATMENT  OF  PHLEGMON.  231 

vessels  and  the  alarming  dyspncea  left  no  alternative  but  death  from  sufEocation  or  an 
incision  of  the  abscess  from  without.  March  9th,  at  2  P.  M. — This  was  done,  evacuat- 
ing about  half  an  ounce  of  pus.  A  drainage-tube  was  introduced  into  the  bottom  of  the 
cavity,  and,  to  limit  the  oozing,  a  compressory  dressing  was  applied.  At  If.  P.  M. — 
Scanty  but  continuous  hemorrhage  set  in  from  the  drainage-tube.  This  being  removed, 
the  cavity  was  plugged  with  strips  of  iodoformed  gauze,  and  the  bleeding  edges  of  the 
incision  were  seared  with  the  thermo-cautery.  At  8.30  P.  M. — The  child  died  of  acute 
anemia. 

March  10th. — Post-mortem  examination  by  Dr.  A.  Seibert  in  the  presence  of  Dr. 
L.  Bopp  and  the  author.  On  the  neck,  close  to  the  posterior  edge  of  the  left  sterno- 
mastoid,  a  cutaneous  incision  was  found  one  inch  in  length,  its  edges  marked  by  a 
dark-red,  bloody  infiltration.  A  probe  entered  the  refcro-pharyngeal  space,  where  it 
could  be  felt  with  the  finger  placed  in  the  oral  cavity.  A  skin-flap  being  raised  and 
turned  upward,  a  couple  of  intumescent,  dark-red  lymph-glands,  situated  near  the  an- 
terior edge  of  the  sterno-mastoid  muscle,  were  exposed.  The  sterno-mastoid  muscle 
was  cut  away  at  its  lower  insertion  and  was  turned  upward.  The  vascular  sheath  was 
opened,  and  the  deep  jugular  vein  and  carotid  artery  were  carefully  examined  and 
found  intact.  A  wall  of  tissue  one  third  of  an  inch  in  thickness  was  found  interposed 
between  these  vessels  and  the  track  occupied  by  the  silver  probe.  The  prevertebral 
interspace  was  found  distended  by  a  dark,  massive,  and  soft  clot,  extending  upward  to 
the  base  of  the  cranium,  and  downward  to  the  level  of  the  third  tracheal  cartilage. 
Cervical  vertebrae  normal. 

Doubtless  it  was  a  case  of  hsemophilism. 

(A  case  of  retro-pharyngeal  infiltration,  simulating  the  symptoms  of  abscess,  was 
seen  by  the  author  in  the  German  Hospital,  in  which  acute  infectious  osteomyelitis 
of  the  second  cervical  vertebra  was  the  cause  of  the  trouble.  Henry  Ludwig,  bartender, 
aged  twenty-one.  February  16,  1885. — High  fever  set  in  with  a  chill  and  stertorous 
breathing.  The  face  was  slightly  cyanosed  and  the  voice  had  a  thick  sound  cliaracter- 
istic  of  retro-pharyngeal  swelling.  The  patient  held  his  neck  rigidly,  and  in  moving 
supported  it  by  his  hands.  A  typhoid  condition  prevailed.  The  house  surgeon  of  the 
German  Hospital  made  a  free  incision  into  the  swelling  occupying  the  retro-pharyngeal 
region,  but  no  pus  escaped.  In  spite  of  weight  extension,  sudden  death  occurred,  March 
20th,  from  compression  of  the  medulla.  Post-mortem  examination  revealed  a  far-gone 
destruction  of  the  second,  third,  and  fourth  cervical  vertebrse.  The  odontoid  process 
was  detached,  and  had  fatally  compressed  the  medulla.) 

Acute  infectious  osteomyelitis  of  the  lower  jaio  occurs  either  in  the  adult 
after  traumatism,  such  as  for  instance  fracture  of  its  entire  thickness  by- 
violence,  or  injury  to  the  alveolar  process  caused  by  the  extraction  of  teeth  ; 
or  spontaneously  in  the  adolescent.  The  latter  form  is  quite  frequent,  and 
results  generally  in  more  or  less  extensive  necrosis  and  the  formation  of 
abscess.  Perforation  usually  takes  place  toward  the  oral  cavity,  though  oc- 
casionally invasion  of  the  submaxillary  capsule  or  the  vascular  intersjDace  is 
observed.  Early  incision  will  allay  pain,  relieve  the  fever,  and  will  prevent 
the  extension  of  suppuration. 

The  treatment  of  necroses  of  the  mandible  was  disposed  of  elsewhere. 

(y8)  Submaxillary  and  Parotid  Cynanche. — Both  the  submaxillary  and 
parotid  salivary  glands  are  inclosed  in  complete  and  very  dense  fascial  en- 
velopes. On  account  of  this  anatomical  peculiarity,  and  in  the  case  of  the 
submaxillary  gland,  the  vicinity  of  the  tongue  and  larynx,  purulent  inflam- 


232  RULES  OF  ASEPTIC   AND  ANTISEPTIC  SURGERY. 

matious  of  these  organs  present  some  peculiarly  grave  features  worthy  of 
special  attention. 

Human  saliva  normally  contains  a  chemical  substance  akin  to  the  pto- 
maines or  to  snake  poison,  that,  like  the  latter,  seems  to  play  an  important 
part  in  the  process  of  digestion.  Whether  an  undue  development  of  this 
albuminoid  substance,  or  exclusively  the  direct  absorption  of  septic  matter 
from  the  oral  cavity  is  at  the  bottom  of  the  septic  inflammations  of  the  sali- 
vary glands,  is  not  known — suffice  to  say,  that  occasionally  one  or  the  other 
of  these  glands  becomes  the  seat  of  supjiurative  inflammation.  Their  resist- 
ant envelope  leads  to  incarceration  of  ichor  and  pus,  to  the  development  of 
enormous  tension  and  its  deleterious  local  and  general  effects — which  are 
dense  infiltration  and  necrosis  of  the  contiguous  soft  parts,  with  dysphagia 
and  suffocative  attacks,  and  a  highly  septic  fever. 

Sublingual  or  Submaxillary  Cynanche  {Ludwig's  Angina). — A  painful, 
deep-seated,  hard  swelling  of  the  submaxillary  region  apjjears,  and  is  quickly 
followed  by  chills  and  high  fever,  the  swelling  rapidly  increasing  in  extent 
and  hardness,  and  the  skin  over  the  submaxillary  gland  turning  dusky  red. 
As  long  as  the  patient  is  up,  his  head  is  held  rigidly  in  one  position,  the 
eyes  moving  in  wide  circles  if  he  wants  to  see  an  object  out  of  his  range  of 
vision.  Or,  if  he  be  unsuccessful,  the  entire  body  is  turned  round  slowly 
to  bring  the  desired  object  within  sight.  The  mouth  is  held  slightly  open, 
the  tongue  is  dry,  the  floor  of  the  mouth  somewhat  oedematous.  Speech  is 
difficult,  as  can  be  seen  from  the  painful  twitchings  of  the  patient's  face 
whenever  he  has  to  say  something.  After  a  while  he  will  seek  the  bed.  The 
face  will  appear  slightly  oedematous  and  cyanosed,  the  eye  has  a  dull  and 
stupid  expression,  the  dry  tongue  is  found  lolling  out  of  the  mouth,  and 
saliva  escaping  alongside  of  it.  The  floor  of  the  mouth  is  very  oedematous, 
and  by  this  time  the  entire  submaxillary  region  will  have  become  swollen 
and  as  hard  as  a  board.  The  labored  snoring  respiration  of  the  patient  gives 
warning  of  the  extension  of  the  oedema  to  the  soft  palate,  fauces,  and  the 
vicinity  of  the  larynx.  The  temperature  indicates  very  high  fever,  and  the 
patient  is  unable  to  allay  his  burning  thirst,  as  swallowing  will  have  become 
impossible.  At  this  stage  oedema  of  the  glottis  may  cause  asphyxia  in  some 
cases,  requiring  immediate  tracheotomy.  In  other  cases  extensive  slough- 
ing of  the  involved  parts  of  the  neck  will  supervene,  and  fatal  hgemorrhage 
may  be  caused  by  erosion  of  large  vessels.  The  grave  sei^ticasmia  alone,  or 
the  extension  of  septic  thrombosis  to  the  cranium  or  right  auricle,  may  end 
in  death. 

All  dilatory  measures,  such  as  hot  or  cold  applications,  will  be  useless, 
or  positively  injurious,  and  the  patient's  salvation  depends  on  a  quick 
appreciation  of  the  true  character  of  the  trouble,  followed  by  prompt  and 
energetic  action. 

Case  I. — It  was  observed  by  tbe  author  during  his  military  service  in  Garrison  Hos- 
pital No.  2  at  "Vienna,  Austria,  in  November,  1872.  During  convalescence  from  a  severe 
form  of  typhoid  fever,  symptoms  of  sublingual  cynanche  appeared  in  a  young  soldier 
treated  in  the  division  for  internal  diseases.     Fomentations  being  employed,  the  swell- 


DIAGNOSIS  AND  TREATMENT   OF  PHLEaMON.  233 

ing  assumed  alarming  proportions.  Suddenly  oedema  of  tlie  glottis  appeared,  and  the 
case  was  transferred  to  the  surgical  division.  The  left  side  and  frontal  region  of  the 
neck  were  found  densely  infiltrated  and  very  hard,  and  tracheotomy  had  to  he  per- 
formed under  unusual  difficulties  by  regimental  surgeon  Dr.  Fillenbaum.  A  number 
of  abscesses  were  encountered,  and  purulent  perichondritis  was  found  to  be  the  immedi- 
ate cause  of  the  oedema  of  the  glottis.  Tracheotomy  relieved  the  dyspnoea,  but  the 
patient  died  soon  afterward  of  septicaemia. 

Case  II. — Jacob  H.,  farmer,  aged  twenty-one,  admitted  to  the  German  Hospital 
January  19,  1886,  presented  a  circumscribed  red  swelling  of  the  left  submaxillary 
region,  that  had  appeared  with  high  fever  two  days  before  admission.  Face  cyanosed, 
expression  dull,  breathing  stertorous;  the  mouth  half  open,  tongue  protruding,  floor  of 
mouth  oedematous.  Temperature,  104"5°  Fahr.  Immediate  incision  according  to  Hil- 
ton-Roser's  method  in  ansesthesia.  About  half  an  ounce  of  thin  ichorous  pus  escaped. 
The  incision  was  enlarged  with  a  probe-pointed  knife,  and  drainage  and  a  moist  dress- 
ing were  applied.  In  the  night  a  short  suffocative  attack  appeared.  January  20th. — 
Temperature,  101°  Fahr.  Cyanosis  and  oedema  of  the  floor  of  month  appreciably 
diminished.  Improvement  continued,  no  necrosis  following,  and  patient  was  discharged 
cured  February  6th. 

Case  III. — William  B.,  clerk,  aged  twenty-two.  Sublingual  cynanche,  character- 
ized by  protrusion  of  tongue  and  very  high  fever.  The  family  attendant  had  treated 
the  case  for  ten  days  by  poulticing,  and  April  3,  1884,  had  incised  the  swelling  in  the 
submaxillary  region.  Relief  followed,  but  in  the  night  alarming  dyspnoea,  due  to  arte- 
rial hsemorrhage,  supervened,  that  rapidly  distended  all  the  interspaces  of  the  left  side 
of  the  neck,  and  threatened  suffocation.  Afril  5th. — Early  in  the  morning  trache- 
otomy was  hastily  performed  by  the  author,  who  found  the  left  side  of  the  neck  enor- 
mously swollen,  and  some  bloody  serum  oozing  out  of  the  small  external  incision  and 
from  the  oral  cavity.  The  source  of  the  latter  bleeding  was  found  in  a  sloughy  per- 
foration of  the  floor  of  the  mouth.  As  hsemorrhage  had  ceased,  only  a  drainage-tube 
was  placed  into  the  external  incision,  and  a  moist  dressing  was  applied.  The  patient 
was  doing  well  April  7th,  when  he  was  seen  by  the  author  the  last  time.  Later  on, 
the  family  attendant  informed  the  author  that  another  external  htemorrhage  had 
occurred  during  the  process  of  detachment  of  the  numerous  sloughs,  requiring  deliga- 
tion  of  a  spurting,  probably  the  facial,  artery.     Patient  recovered 

Case  IV. — C.  S.,  watchman,  aged  thirty-two.  Sublingual  cynanche  of  thirty-six 
hours'  standing.  Extensive  hard  infiltration  of  anterior  and  left  side  of  neck.  Dys- 
phagia, dyspnoea,  tongue  protruding.  May  5,  1886. — Incision  by  preparation  at  Ger- 
man Hospital.  The  thickened  capsule  of  the  submaxillary  gland  being  divided,  a  small 
cavity  containing  about  a  half  drachm  of  ichorous  pus  and  debris  was  exposed  and 
drained.  It  just  admitted  the  tip  of  the  index-finger.  Immediate  improvement  of  all 
symptoms.     Patient  was  discharged  cured  May  20th. 

Parotid  Cynanche. — This  may  develop  iudepeiidently  or  complicated 
with  orchitis  during  and  after  acute  infectious  diseases,  such  as  typhoid  and 
scarlet  fever,  small-pox,  or  the  measles,  or  may  be  the  direct  continuation  of 
an  attack  of  mumps.  It  is  not  as  alarming  in  rapidity  of  development  as 
the  sublingual  form,  but  is  apt  to  be  much  more  tedious  on  account  of  the 
gradual  breakdown  of  the  lobulated  structure  of  the  parotid  gland.  One 
lobe  after  another  succumbs  to  the  suppurative  process,  and  an  intermina- 
ble series  of  abscesses  make  their  appearance.  Generally  perforation  out- 
ward is  the  rule  ;  occasionally,  however,  perforation  into  the  spheno-max- 


234  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

illary  fossa,  and  extension  into  the  intermuscular  planes  of  the  neck,  with 
all  its  dangers,  ensues.  Necrosis  of  the  interlobular  septa  is  a  common 
occurrence.  On  account  of  the  necessity  of  avoiding  the  temporal  artery 
and  facial  nerve,  long  incisions  are  imj^racticable.  They  must  be  small, 
and  several  should  be  made  to  afford  sufficient  drainage. 

Case. — II.  S.,  merchant,  aged  fifty,  commenced  to  suffer  about  Christmas,  1885, 
from  a  furuncle  of  the  external  meatus.  This  led  to  suppuration  of  the  lymphatic 
gland  normally  found  in  front  of  the  meatus,  and,  under  a  poulticing  treatment,  to 
an  involvement  of  the  parotid  gland.  The  patient  was  seen  by  the  author  January 
11,  1886,  and  exhibited  a  large,  non-fluctuating,  very  dense  swelling  of  the  right 
parotid  region,  with  a  temperature  of  104°  Fahr.  His  right  eye  could  not  be  closed 
entirely  (paresis  of  the  facial  nerve),  and  he  was  unable  to  separate  the  jaws  to  the 
slightest  extent.  Besides,  repeated  chills,  sleeplessness,  and  the  intense  pain  radi- 
ating to  the  diverse  branches  of  the  trigeminal  nerve,  had  demoralized  the  man  com- 
pletely. A  vertical  incision  placed  just  in  front  of  the  external  meatus  by  careful 
preparation  released  a  large  mass  of  pus.  The  relief  was  very  great,  and  the  patient 
left  the  house  five  days  later  to  be  treated  at  the  author's  oflBce,  where  he  repaired 
daily  for  many  weeks  longer,  as  the  involvement,  and  breaking  down  of  new  lobules 
of  the  parotid  gland  made  frequent  irrigation  and  constant  drainage  a  necessity.  He 
was  discharged  cured  March  28th.  By  October  the  paresis  of  the  orbicularis  palpe- 
brarum had  disappeared. 

(y)  Acute  Glandular  Abscesses  of  the  Anterior  a.nd  Lateral  Cervical 
Regions. — They  are  caused  by  absorption  of  active  micro-organisms  depend- 
ent on  inflammatory  processes  of  the  oral  and  nasal  cavities,  the  pharynx, 
larynx,  the  lower  jaw,  and  the  mastoid  region.  They  have  to  be  well  dis- 
tinguished from  cold  or  chronic  abscesses  of  the  same  region.  Their  onset 
is  sudden  ;  pain  and  fever  rapidly  develop,  with  deejD-seated  dense  infiltra- 
tion, and  gradually  the  corresponding  side  of  the  neck  becomes  oedematous. 
Inflammations  in  the  oral  cavity,  the  tongue,  the  larynx,  and  the  lower  jaw 
produce  an  involvement  of  the  glands  in  the  2}erivascular  space.  They  can 
be  felt  somewhat  in  front  of  the  sterno-mastoid  muscle,  extending  upward 
toward  the  angle  of  the  jaw,  and  are  commonly  known  as  "submaxillary" 
glands.  Affections  of  the  temporal,  auricular,  and  mastoid  regions,  and  of 
the  pharynx,  nasal  cavity,  and  oesophagus,  on  the  other  hand,  are  generally 
followed  by  intumescence  or  suppuration  of  the  glands  situated  in  the  in- 
termuscular  space.  They  can  be  felt  behind  the  posterior  margin  of  the 
sterno-mastoid,  and  their  suppuration  is  apt  to  extend  in  the  direction  of 
the  supraclavicular  space. 

The  question  of  when  to  incise  these  abscesses  should  not  be  made  de- 
pendent upon  the  presence  of  fluctuation,  as  the  worst  and  most  virulent 
cases  will  have  wrought  infinite  mischief  long  before  the  appearance  of 
fluctuation.  In  very  virulent  cases,  marked  by  violent  general  symptoms 
and  rapid  local  spread,  incision  should  be  made  at  once  after  Hilton-Eoser's 
method,  as  relief  from  tension  is  the  most  urgent  requisite  to  prevent  slough- 
ing and  possible  erosion  of  vessels.     Anaesthesia  is  indispensable. 

Where  the  symptoms  are  less  violent,  the  spread  less  rapid,  maturing  of 
the  abscess  may  be  awaited  in  case  the  joatients  are  very  averse  to  an  incision. 


DIAGNOSIS  AND  TEEATMENT  OF  PHLEGMON.  235 

But  the  responsibility  for  the  consequences  of  delay  should  be  declined  by 
the  physician. 

Case. — Lonis  Lebowitsch,  aged  twenty-seven,  presser.  December  15,  1886. — Pain- 
ful hard  swellings  developed  in  the  pretracheal  and  both  submaxillary  regions  with  a 
severe  chill.  Previous  to  this  the  patient  had  been  suffering  from  a  "  sore  throat  "  for 
a  few  days.  The  family  physician  advised  poulticing,  wliich,  as  usual,  was  enthusiasti- 
cally attended  to  by  the  patient's  female  relatives.  The  swellings  continued  to  grow  in 
size;  fever  and  sleeplessness  were  unabated.  December  25th. — Suddenly  an  enormous 
increase  of  the  swellings  in  front  and  on  the  left  side  occurred,  with  dyspncea  and 
dysphagia,  which  induced,  December  29th,  the  patient's  transfer  to  Mount  Sinai  Hos- 
pital. Following  a  hasty  summons  the  author  found  the  patient  sitting  up  in  bed,  his 
head  held  erect,  the  neck  increased  to  double  its  circumference,  its  skin  red,  swollen, 
and  shining  like  a  large-sized  sausage.  Boggy  fluctuation  everywhere.  Most  intense 
thirst  with  absolute  disability  to  swallow  even  fluids ;  wheezing,  long-drawn  respira- 
tion with  considerable  dyspnoea,  which  became  augmented  to  an  alarming  degree  by 
the  reclining  posture.  Examination  of  the  fauces  revealed  a  swelling  of  the  retro- 
faucial  soft  tissues,  and  almost  complete  contact  of  the  slightly  intumescent  tonsils. 
Two  incisions,  one  behind  the  posterior  margin  of  the  sterno-mastoid  muscle,  the  other 
a  little  below  the  thyroid  gland,  released  about  a  quart  of  a  dark-red  gory  liquid,  streaked 
with  pus.  This  was  followed  by  an  immediate  disappearance  of  the  dyspnoea,  and  the 
patient  was  able  at  once  to  allay  his  thirst  by  copious  drafts  of  water.  A  digital  ex- 
amination of  the  cavities  opened  by  the  incisions  showed  them  to  communicate  freely. 
The  pulsating  carotid  could  be  distinctly  felt,  lying  exposed  behind  a  large,  roundish 
mass  of  blood-clot,  freely  projecting  into  the  lateral  cavity,  and  seemingly  attached  to 
the  pharyngeal  wall. 

Two  stout  drainage-tubes  were  placed  in  the  incisions,  the  remaining  clots  were 
washed  out  by  gentle  irrigation,  and  a  large,  moist  dressing  was  applied.  The  fever 
fell  at  once  from  103°  Fahr.  to  100°  Fahr.,  but  rose  the  following  day  to  103°  Fahr., 
as  the  incisions  were  clearly  insufficient  for  the  drainage  of  the  enormous  cavity.  More- 
over, there  was  still  considerable  oozing  present,  and  therefore  it  was  deemed  proper 
to  anaesthetize  the  patient  again,  for  the  sake  of  a  thorough  exploration,  drainage,  and 
possibly  prevention  of  further  haemorrhage.  A  fluctuating  place  just  above  the  clavicle 
was  incised,  and  was  found  communicating  by  a  narrow  channel  with  the  upper  cavity. 
Both  of  the  lateral  incisions  were  now  united  by  preparation,  the  external  jugular  vein 
being  first  secured  by  double  ligature  and  divided,  and  thus  by  this  long  incision  the 
interior  of  the  large  abscess  was  exposed  to  view.  The  cavity  extended  from  the 
clavicle  to  the  base  of  the  cranium.  In  it  lay  exposed  the  carotid  artery  and  the  jugu- 
lar vein,  to  the  upper  portion  of  which  anteriorly  a  large,  firm,  and  irregular  clot  was 
found  adhering,  indicating  where  the  haemorrhage  had  come  from.  The  loose  clots 
were  all  cleared  out,  hut  the  one  adherent  to  the  jugular  was  left  undisturbed.  Copi- 
ous oozing  from  the  abscess  walls  was  observed,  and  checked  by  a  loose  packing  of 
iodoformed  gauze,  preceded  by  thorough  irrigation.  The  patient  was  discharged 
cured  on  January  27,  1887. 

The  preceding  case  vividly  illustrates  the  dangers  of  protracted  poultic- 
ing in  deep-seated  lymphatic  abscesses.  Sloughing  of  the  wall  of  an  adja- 
cent large  vein  caused  a  most  serious  complication  by  secondary  haemorrhage. 
Arterial  heemorrhage  would  have  undoubtedly  produced  rapid  suffocation. 

(8)  Glandular  Abscesses  of  the  Temporal,  Mastoid,  and  Occipital  Re- 
gions.— Suppurative  processes  located  in  the  external  ear  will  occasionally 
32 


936  EULES  OF  ASEPTIC   AND  ANTISEPTIC  SURGERY. 

extend  to  one  or  more  lympluitic  glands,  subfuscially  situated  in  front  of 
the  external  meatus  of  the  ear,  and  in  close  vicinity  to  the  parotid  gland. 
They  produce  very  violent  general  and  local  symptoms,  and  require  early 
attention,  as  a  subsequent  involvement  of  the  parotid  gland  is  very  apt  to 
occur. 

Suppuration  of  the  mastoid  cells  is  the  most  common  form  of  extension 
of  a  purulent  otitis  of  the  external  or  middle  ear.  Its  symptoms  bear  great 
resemblance  to  those  of  acute  osteomyelitis,  and  require  prompt  attention  on 
account  of  the  ])ossibility  of  necrosis  and  the  involvement  of  the  meninges, 
brain,  or  lateral  sinus.  Where  intense  swelling  indicates  the  presence  of 
purulent  periostitis  of  the  mastoid  process,  a  free  incision  of  all  the  soft  parts 
down  to  the  bone  will  often  give  great  relief.  But,  where  the  interior  of  the 
cancellous  structure  of  the  mastoid  process  is  the  seat  of  the  disease,  noth- 
ing short  of  a  free  opening  of  its  interior  will  avail.  Formerly,  this  opera- 
tion was  done  with  the  aid  of  the  trephine,  an  instrument  the  penetration 
of  which  is  somewhat  beyond  the  supervising  control  of  the  surgeon.  At 
present  mallet  and  chisel  are  used  for  this  purpose  with  greater  advantage. 
The  chisel  should  be  held  tangentially  to  the  external  surface  of  the  mastoid 
process,  thin  layers  of  bone  being  pared  off  in  succession,  until  the  suppurat- 
ing focus  is  freely  exposed.  Thus  injury  to  the  lateral  sinus  can  be  safely 
avoided.  Coj^ious  irrigation  with  a  luarm  solution  of  corrosive  sublimate 
and  a  moist  dressing  are  advisable.  The  cases  in  which  early  operating  has 
prevented  necrosis  will  heal  very  promptly.  Necrosis  will  retard  the  cure 
considerably,  and  may  require  a  second  or  even  a  third  operation  for  the 
removal  of  sequestra. 

In  neglected  cases  spontaneous  perforation  through  the  periosteum  will 
occur,  and  an  external  abscess,  located  posteriorly  to  the  sterno-mastoid 
muscle,  will  appear.  The  tendency  of  its  extension  is  toward  the  "inter- 
muscular space,"  that  is,  downward  into  the  supraclavicular  fossa. 

Occasionally  the  process  extends  backward  and  upward  upon  the 
occiput. 

Case  I. — Fred.  Biitlis,  bnker,  aged  eighteen,  admitted  to  ear  department  of  German 
Hospital,  December  17,  1883,  with  purulent  catarrh  of  the  middle  ear  and  suppuration 
of  mastoid  cells.  Wilde's  incision  and  extraction  of  some  sequestra  from  the  external 
meatus  were  practiced  by  Dr.  J.  Simrock.  A  phlegmon  of  the  left  occipital  region, 
starting  from  a  sinus  below  the  mastoid  process,  having  set  in,  patient  was  transferred, 
March  25,  1884,  to  the  surgical  department.  March,  S6th. — High  fever  and  violent 
headache  with  vomiting.  Several  incisions  laid  open  an  irregular  cavity  situated  be- 
hind the  ear  and  extending  downward  toward  the  neck.  On  pressure,  a  large  quantity 
of  pus  oozed  out  of  a  recess  between  exuberant  granulations  near  the  lower  anterior 
angle  of  the  parietal  bone.  These  being  scraped  away,  a  sequestrum,  about  one  square 
inch  in  circumference,  and  comprising  the  whole  thickness  of  the  skull,  was  extracted. 
Pulsation  of  the  bottom  of  the  cavity  thus  exposed  was  clearly  discernible.  Healing 
progressed  without  interruption,  the  purulent  discharge  from  the  middle  ear  ceased, 
and  patient  was  discharged  cured,  April  17,  1884,  with  a  deeply  indented  scar.  In 
October,  1886,  he  presented  himself,  complaining  of  epileptic  seizures  that  had  appeared 
in  July,  1886. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  237 

Case  II.— E.  N.,  merchant,  aged  twenty-five.  Had  been  suffering  from  purulent 
otitis  media  for  a  long  time.  Suppuration  of  the  mastoid  cells,  and  formation  of  an 
external  inframastoidal  abscess,  led  to  incision,  which  was  done  by  Dr.  E.  Gruenmg, 
under  whose  care  the  patient  had  been  for  some  tinie.  A  phlegmonous  inflammation 
of  the  neck  following,  January  22,  1882,  a  consultation  was  called,  when  a  number 
of  deep  incisions  back  of  the  sterno-mastoid  muscle  were  made,  and  the  abscesses  were 
drained.  The  probe  felt  bare  bone  in  the  mastoid  notch.  Subsequently  a  considerable 
quantity  of  bony  grits  passed  away  witb  the  secretions,  and  the  carbolic  lotion  injected 
into  the  drainage-tubes  entered  the  oral  cavity.  End  of  March,  the  patient  was  dis- 
charged cured,  and  remained  well  until  September,  1886,  when  he  was  seen  by  the 
author  suffering  from  dementia. 

b.  Mammary  and  Retro-mammary  Abscess. — Excoriations  and  fissures,  so 
common  upon  the  nipples  of  nursing  women,  are  the  portals  through  which 
infection  enters  the  multitudinous  lymphatics  of  the  mammary  gland.  A 
preparatory  treatment  of  the  nipples  during  the  last  period  of  pregnancy  is 
the  best  preventive  of  the  formation  of  fissures.  It  should  consist  in  molli- 
fying, and  removal  by  bathing  in  warm  soap-water,  of  the  thick  layers  of 
effete  epidermis,  usually  present  around  the  openings  of  the  lacteal  ducts. 
The  tender  epidermis  thus  exposed  will  be  hardened,  and  will  become  fit  to 
resist  the  manifold  injuries  unavoidable  during  lactation. 

Should  rhagades  develop,  a  thorough  disinfection  with  corrosive-subli- 
mate lotion  (1  : 1,000),  followed  by  touching  of  the  fissures  with  a  well- 
sharpened  stick  of  nitrate  of  silver,  will  in  most  cases  lead  to  a  cure  of  the 
painful  disorder.  Nursing  should  be  either  stopped  and  the  milk  removed 
with  the  breast-pump,  or,  if  continued,  should  be  only  permitted  with  a 
nipple-shield,  until  the  fissure  is  closed. 

Disregard  of  these  precautions  will  frequently  lead  to  suppuration. 

A  large  proportion  of  the  inflammatory  processes  of  the  breast  are  non- 
suppurative, the  intumescence,  redness,  and  occasionally  smart  fever  being 
set  up  by  a  retention  of  the  thickish  milk  of  first  lactation.  Sometimes 
fluctuation  will  be  felt,  and,  if  an  incision  is  made,  no  pus — only  milk — will 
escape.  Absence  of  an  infection  by  micro-organisms  must  be  assumed  in 
these  cases,  which,  as  a  rule,  get  well  without  suppuration  by  simple  topical 
treatment,  consisting  of  the  application  of  moist  heat  and  methodical  com- 
pression. 

Hence,  not  all  cases  of  acute  mastitis  terminate  in  abscess.  Winckel 
saw,  in  the  Dresden  Lying-in  Hospital,  ninety-one  out  of  a  total  of  one 
hundred  and  thirty-six  cases  of  mastitis  get  well  without  suppuration. 
Therefore,  topical  treatment  with  the  ice-bag  or  cold-water  coil  (by  both  of 
these  the  secretion  of  milk  is  materially  reduced),  or,  if  opposition  to  these 
be  encountered,  tepid  or  warm  applications,  aided  by  support  and  gentle 
compression  of  the  breast,  should  be  first  tried. 

Should,  however,  fever  and  the  local  symptoms  persist  or  increase,  and 
fluctuation  become  apparent,  incision  and  drainage  are  the  measures  to  be 
applied. 

Abscesses  of  the  mammary  gland  proper  are  either  suhcutaneous,  then 
generally  located  about  the  nipple ;  or  are  more  deep-seated,  that  is,  intra- 


238  RULES  OF  ASEPTIC   AND   ANTISEPTIC  SURGERY. 

glandular.     A  third  form  of  breast  abscess  is  the  suppuration  of  the  loose 
connective  tissue  found  heliind  the  gland  :  retro-mammary  abscess. 

Its  location  in  the  vicinity  of  the  nipple  and  the  early  appearance  of 
well-defined  fluctuation  will  readily  characterize  the  subcutaneous  abscess. 

When  the  deeper  parts  of  the  glandular  tissue  proper  become  the  seat  of 
an  abscess,  general  swelling  of  the  breast-gland  is  most  prominent.  The 
skin  of  the  mamma  becomes  red  and  oedematous,  and  one  or  more  jjitting 
points  can  be  soon  detected.  But  the  hreast  is  freely  movable  as  a  2vhole 
upon  the  pedoralis  fascia. 

In  retro-mammary  suppuration  the  breast  is  immovable,  and  firmly 
attached  at  its  base.  The  glandular  tissue  is  soft  and  normal,  unless  a 
combination  of  mammary  and  retro-mammary  suppuration  be  present. 
Deep  fluctuation  can  be  detected  by  careful  palpation. 

Incision  of  the  more  extensive  abscesses  of  the  breast  should  ahvays  be 
done  under  ancesthesia,  as  the  unavoidable  pain  associated  with  thorough 
work  is  too  great  to  be  endured  ;  and  the  measures  must  be  thorough  to 
give  a  prompt  result,  as  nothing  is  more  unsatisfactory  than  an  insufficient 
or  improperly  placed  incision.  Suppuration  is  not  limited  thereby,  new 
points  of  fluctuation  develop,  and  the  interminable  process,  with  fever,  sleep- 
lessness, and  the  drain  upon  the  system,  lead  to  serious  emaciation  and 
lamentable  demoralization  of  both  jiatient  and  physician.  Antiseptic  pre- 
cautions, consisting  of  a  thorough  scrubbing  of  the  surgeon's  hands  and  of 
the  patient's  breast  with  soap  and  brush,  and  subsequent  rubbing  off  with 
corrosive-sublimate  lotion  (1  : 1,000),  should  never  be  neglected.  There  are 
microbial  cultures  of  various  intensity  of  virulence,  and  the  touch  of  an 
unclean  finger  may  intensify  an  otherwise  comparatively  bland  form  of  sup- 
puration, or  may  add  the  poison  of  erysipelas  to  that  of  simple  suppturation. 

All  incisions  penetrating  the  glandular  tissue  should  be  placed  radially, 
so  as  to  avoid  injury  to  the  lacteal  ducts  as  much  as  possible. 

A  place  of  fluctuation  being  marked,  the  knife  is  rapidly  thrust  into  the 
abscess,  if  the  thickness  of  tissues  to  be  cut  through  is  not  too  great.  In 
the  latter  case,  Hilton-Eoser's  method  is  safer  and  preferable,  on  account  of 
the  possibility  of  haemorrhage  from  a  deep-seated  vessel. 

XoTE. — Billroth  recounts  a  case  in  which  he  caused  uncontrollable  and  very  serious  haemor- 
rha<'e  by  cutting  a  large  branch  of  the  external  mammary  artery.  The  loss  of  blood  was  alarm- 
in"',  and  so  beyond  control  that,  after  having  unsuccessfully  tried  a  number  of  the  usual  measures, 
he  finallv  injected  the  abscess  cavity  with  a  quantity  of  turpentine  oil,  that  happened  to  be 
•within  reach.  The  bleeding  was  stopped,  but  a  formidable  gangrenous  phlegmon  brought  the 
patient  very  near  the  grave.     She  recovered,  however. 

As  soon  as  the  well-dilated  dressing  forceps  is  withdrawn,  the  index  of  the 
left  hand  is  slipped  into  the  cavity,  and  a  gentle  exploration  of  its  interior  is 
carefullv  made.  Wherever  a  recess  extends  toward  the  skin,  the  tissues  are 
raised  upon  the  tip  of  the  left  index-finger,  the  skin  and  fascia  are  incised, 
and  the  dressing  forceps  is  introduced  along  the  grooved  director  in  the  well- 
known  manner.  In  this  way  a  number  of  short  counter-incisions  can  be  made 
with  very  little  haemorrhage.     Stout  drainage-tubes,  reaching  just  within 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  239 

the  cayitj,  are  nest  introduced,  and  the  abscess  is  well  washed  out  with  the 
mercuric  lotion.  Oozing  from  the  abscess  walls,  which  is  sometimes  con- 
siderable, will  also  be  checked  thereby.  After  this  the  breast  should  be 
grasped  and  gently  compressed  between  the  extended  hands  as  a  test, 
ivliether  all  recesses  had  been  duly  emptied  or  not.  The  appearance  of 
additional  masses  of  j^us  will  be  a  proof  that  something  was  overlooked, 
and  renewed  search  must  be  instituted  to  find  and  drain  the  OTerlooked 
recess. 

XoTE  AND  Case. — The  observance  of  this  simple  rule  led  to  the  recognition  of  a  very  interesting 
and  rare  form  of  suppurative  mastitis.  Mrs.  C.  F.,  primipara,  admitted  to  Mount  Sinai  Hospital 
two  weeks  after  her  confinement,  with  abscess  of  the  breast.  Had  very  little  fever.  She  was  anaesthe- 
tized December  20, 1886,  and,  four  fluctuating  spots  situated  just  above  and  near  the  nipple  being 
incised,  the  finger  was  slipped  into  one  of  the  incisions,  and  found  the  irregular  and  tortuous 
cavities  communicating  with  each  other.  A  large  number  of  smaller  cavities  occupying  the 
upper  half  of  the  mammary  gland  were  entered,  and  the  intervening  bridges  of  tissue  were 
broken  down  with  the  finger.  Haemorrhage  was  very  scanty.  The  cavity  was  washed  out,  and, 
gentle  pressure  being  applied,  an  additional  large  mass  of  thick  pus  escaped.  A  long  incision 
uniting  the  two  most  distant  primary  incisions,  and  passing  through  the  entire  width  of  the  gland, 
was  now  made.  It  exposed  the  cavity,  which  was  found  lined  with  necrosed  shreds  of  glandu- 
lar tissue.  The  abscess  walls  exuded  on  firm  pressure  from  hundreds  of  invisible  openings 
separate  drops  of  creamy  pus.  A  portion  of  the  indurated  wall  of  the  cavity  was  pared  off, 
until  seemingly  healthy  tissue  was  encountered.  Pirm  pressure  being  repeated,  the  same  exuda- 
tion of  pus  from  innumerable  pores  of  the  cut  sui'face  was  observed.  The  section  had  a  deep- 
yellow  tinge,  and  presented  the  density  of  fibromatous  tissue.  The  lower  half  of  the  breast-gland 
was  normal  and  secreted  milk.  An  iodoform  dressing  was  applied,  and  remained  undisturbed 
until  December  2'7th,  when  the  patient  complained  of  pain  and  exhibited  some  fever.  The 
dressings  being  removed,  a  new  abscess  was  found  and  incised  near  the  upper  margin  of  the 
long  incision.  The  old  abscess  cavity  was  granulating,  but  its  walls  still  exhibited  the  peculiar 
appearance  of  a  large  number  of  distinct  pus-drops  on  pressure.  The  wretched  general  con- 
dition of  the  patient,  and  the  presumably  interminable  suppuration  to  be  expected  under  the 
circumstances  suggested  exsection  of  the  affected  parts  of  the  breast  as  the  most  rational 
measure.  This  step,  however,  was  strenuously  opposed  by  the  patient,  and  she  left  the  hospital 
uncured. 

Apparently  we  had  in  this  case  a  form  of  purulent  mastitis  where  the 
supjouratiye  process  was  jDrimarily  located  in  the  lacteal  ducts,  the  intersti- 
tial connective  tissue  assuming  the  character  of  shrinking  fibroid  or  cica- 
tricial tissue,  as  in  non-suppurating  interstitial  mastitis.  The  contraction  of 
the  interstitial  tissue  led  to  closure  of  the  lacteal  ducts  and  to  retention ; 
this  to  perforation  of  the  lacteal  ducts  and  extension  of  the  supjDuration  into 
the  interstitial  tissue  ;  this,  finally,  to  the  formation  of  a  large  number  of 
disseminated  abscesses  and  necrosis.  Throughout,  the  case  exhibited  un- 
usual characteristics  :  well-circumscribed  localization,  low  fever  with  appall- 
ing destruction  of  tissues,  and  their  curious  permeation  with  canals,  that 
could  be  nothing  but  lacteal  ducts,  filled  with  creamy  pus.  As  drainage 
and  disinfection  of  the  infected  lacteal  ducts  were  imjDossible,  ablation  of  the 
diseased  part  of  the  gland  was  clearly  the  proper  way  to  terminate  the 
process. 

Retro-mammary  abscesses  usually  point  near  the  lower  margin  of  the 
breast-gland.     They  should  be  treated  like  other  deep-seated  abscesses,  by 


240 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


incision  and  drainage,  care  being  taken  to  establisli  the  latter  in  the  most 
dependent  position. 

When  tlie  operation  is  completed,  safety-pins  are  thrust  through  the  pro- 
jecting ends  of  the  drainage-tubes  near  the  surface  of  the  skin,  and  they  are 
trimmed  off  short.  A  small  ring  of  iodoformed  gauze  is  placed  underneath 
the  safety-pin  around  the  drainage-tube,  to  prevent  its  being  overlapped  by 
the  edges  of  the  wound,  and  a  moist  antiseptic  dressing  is  applied.  In  the 
absence  of  fever  and  pain,  and  if  the  dressings  remain  unpermeated  by  secre- 
tions, they  need  not  be  changed  before  three  or  four  days,  when  the  drain- 
age-tubes can  be  either  wholl}^  removed,  or  one,  having  previously  been 
somewhat  shortened,  can 
be  left  in  the  most  de- 
pendent incision  till  the 
following  change  of  dress- 
ings. 

Where  shreds  of  ne- 
crosed tissue  are  still  ad- 
herent to  the  walls  of  the 
abscess,  secretion  will  be 
somewhat  more  copious, 
and  permeation  of  the  dressings 
will  require  daily  changes  until 
the  necrosed  parts  come  away. 
During  this  time,  however,  if 
drainage  be  adequate,  all  the  pus 
secreted  should  be  contained  in  the 
dressings,  and  none  in  the  tooutid.  After  detachment  of  the  necrosed  parts, 
secretion  will  become  scanty  and  watery  in  character,  and  removal  of  the 
tubes  will  be  followed  by  rapid  closure  of  the  wound. 

In  cases  where  drainage  is  inadequate,  fever  and  pain  will  persist,  and 
secretion  will  remain  profuse.  The  dressings  will  need  frequent  I'euewal, 
they  will  be  rapidly  soaked  with  pus,  and  the  wound  itself  will  contain 
more  or  less  of  it.  This  can  be  easily  ascertained  by  gentle  pressure,  which 
will  cause  a  copious  flow  of  pus.  Frequent  irrigation  is  a  very  imperfect 
substitute  of  proper  drainage  ;  therefore,  the  making  of  a  well-placed  incis- 
ion should  remedy  the  shortcoming. 

c.  Empyema. — Infection  of  the  pleura  by  pyogenic  organisms,  either 
through  metastatic  processes  or  by  direct  extension  from  the  bronchi  and 
lungs  ;  from  without  by  injury,  or  from  purulent  affections  of  the  vicinal 
regions,  as,  for  instance,  perinephritic  or  liver  abscess,  leads  to  the  forma- 
tion of  empyema — that  is,  an  accumulation  of  pus  within  the  pleural  cavity. 
The  diagnosis  of  the  affection  is  based  upon  the  fever,  dyspnoea,  the  absence 
of  respiratory  murmur,  the  dull  percussion  sound,  rigidity  of  the  affected 
side  of  the  thorax,  flatness  of  the  intercostal  depressions,  and  more  or  less 
marked  oedema  of  the  integument  over  the  site  of  the  accumulation. 

Probatory  puncture  with  a  hypodermic  needle  will  usually  yield  pus. 


Fig.  17; 


-Dressing  for  mammary  abscess, 
or  empyema. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  241 

The  proper  treatment  consists  of  timely  incision,  disinfection,  and  drain- 
age under  antiseptic  cautela3. 

Management  of  Recent  Cases  of  Empyema. — The  thorax  of  the  ansesthe- 
tized  patient  is  cleansed  and  disinfected,  and  an  incision  is  made,  from  two 
to  three  inches  in  length,  in  the  eighth  intercostal  space,  parallel  with  the 
ribs,  and  a  little  back  of  the  axillary  line.  The  skin  and  muscles  are  grad- 
ually divided  down  to  the  pleura,  which  is  then  incised.  The  sudden  gush 
of  pus  is  checked  and  moderated  by  the  pressure  of  the  tip  of  the  finger,  as 
too  sudden  evacuation  of  the  tense  accumulation  may  lead  to  rupture  of  ves- 
sels, or,  in  the  case  of  empyema  of  the  left  pleural  cavity,  to  fatal  embolism 
of  the  pulmonary  artery.  In  these  cases  the  heart  is  displaced  to  the  right 
side,  and  any  clots  that  may  have  formed  within  the  right  auricle  could  be 
easily  detached  by  a  sudden  change  of  the  heart's  position.  This  accident 
has  occurred  once  to  the  author.  However,  it  did  not  take  place  on  the 
operating-table,  but  happened  several  days  after  the  operation. 

Case. — Helen  Muller,  aged  eleven.  Empyema,  with  two  fistnlse,  of  six  years' 
standing.  Great  emaciation  ;  retention  of  fetid  pus;  the  heart  displaced  to  the  right 
side.  February  27,  1883. — Exsection  of  two  ribs,  multiple  incisions,  and  drainage  of 
the  fetid  abscess.  Daily  irrigation  produced  a  marked  remission  of  the  fever,  and 
everything  seemed  to  progress  favorably,  when,  March  6th,  while  playing  in  bed,  the 
child  suddenly  became  cyanosed,  and  fell  back  dead.  No  post-mortem  examination 
could  be  had.     Death  was  doubtless  caused  by  embolism  of  the  pulmonary  artery. 

The  pleural  incision  should  be  ample,  as  otherwise  voluminous  fibrinous 
pseudo-membranes  may  clog  the  exit  of  pus.  A  large-calibered  drainage- 
tube,  reacMng  just  within  the  pleural  sac,  is  inserted,  and  is  at  once  secured 
with  a  stout  safety-'pin,  to  prevent  its  being  lost  in  the  abscess.  This 
occurred  in  one  case  treated  at  the  German  Hospital,  and  a  good  deal  of 
trouble  was  experienced  in  finding  the  lost  tube. 

Case. — Fridolin  Jaehle,  laborer,  aged  forty-three,  saccated  empyema  of  eight  weeks' 
standing.  February  9,  ISSJf. — Posterior  incision  in  the  eighth  intercostal  space ;  evacu- 
ation of  a  large  quantity  of  pus.  A  drainage-tube  was  inserted,  but  slipped  out  of  the 
fingers,  and  was  lost  in  the  cavity.  The  incision  was  sufHciently  enlarged  to  admit  two 
■fingers,  and  then  a  sort  of  a  diaphragm  could  be  felt  separating  two  intercommunicat- 
ing cavities.  A  counter  incision  was  made  in  the  mammary  line,  and  the  lost  drainage- 
tube  was  extracted  therefrom.  Drainage-tubes  properly  fastened  with  safety-pins  were 
inserted,  and  the  cavity  was  irrigated  with  carbolic  lotion.  Moist  dressings  were  ap- 
plied.    April  18th. — Patient  was  discharged  cured. 

Washing  of  the  pleural  cavity  with  warm  mercuric  solution  (1  :  5,000) 
thrown  from  an  irrigator  should  be  done,  until  the  fluid  returns  in  a  limpid 
state.  Then  a  final  flushing  with  corrosive-sublimate  lotion  of  the  strength 
of  1  :  1,000  should  follow,  and  good  care  should  be  taken  to  drain  off  the 
last  vestige  of  the  solution  by  turning  the  patient  so  as  to  bring  the  incision 
nethermost.  A  very  ample  moist  dressing  should  envelop  the  patient's 
thorax. 

As  long  as  the  temperature  remains  normal  or  slightly  elevated,  and  the 
dressing  clean,  no  change  is  necessary.     Usually,  however,  the  dressings 


242  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

will  be  soiled  within  twenty-four  hours,  and  then  they  must  be  changed. 
But  irrigation  should  not  be  employed  so  long  as  the  patient's  temperature 
is  normal.  Only,  if  renewed  fever  appear,  or  the  secretion  assume  a  fetid 
odor,  will  repetition  of  the  irrigation  be  necessary.  In  fresh  empyemata, 
especially  of  children,  one  irrigation  thoroughly  done  at  the  time  of  the 
operation  loill  he  found  siifficient.  But  in  some  favorable  cases  of  adults 
the  same  smooth  course  of  healing  may  be  observed.  The  discharges  will 
gradually  diminish,  they  will  lose  their  purulent  character,  and  will  become 
watery  and  scanty.  As  soon  as  this  is  observed,  the  drainage-tube  should 
be  removed,  and  within  four  or  six  weeks  from  the  operation  the  cavity  will 
be  healed  by  renewed  adhesion  of  the  costal  and  pulmonal  j)]eura.  The 
lung  will  dilate  to  its  normal  extent,  and  the  universal  adhesion  of  the 
pleural  surfaces  will  gradually  give  way  to  constant  attrition,  until  the 
mobility  of  the  lung  and  the  normal  state  of  things  are  re-established. 

Case. — Henry  Fennell,  furniture-dealer,  aged  thirty.  Empyema  on  left  side  of  four 
weeks'  duration.  February  1,  1880. — Communication  with  a  larger  bronchus  spon- 
taneously established,  giving  rise  to  uncontrollable  fits  of  coughing,  which  have  ex- 
hausted the  patient  to  a  dangerous  degree.  February  6th. — Incision,  drainage,  and 
irrigation  with  a  five-per-cent  solution  of  carbolic  acid.  The  cough  stopped  at  once; 
the  fever  fell  off.  February  i7«^.— Discharge  very  scanty  and  watery ;  drainage-tubes 
were  removed.  February  19th. — Sudden  rise  of  temperature,  with  chill.  February 
20th. — Pleuritic  serous  effusion  on  right  side.  March  1st. — Effusion  on  right  side  begins 
to  be  absorbed.  Left  lung  dilated  to  nearly  its  normal  compass.  March  6th. — Exuda- 
tion in  right  pleura  has  disappeared.     March  i^f A.— Patient  was  discharged  cured. 

Lateral  curvature  of  the  spine  is  a  prominent  symptom  of  long-continued 
empyema,  and  is  very  hard  to  cure.  The  moderate  amount  of  lateral  curva- 
ture that  goes  along  with  recent  empyema  disappears  with  the  restoration 
of  the  function  of  the  compressed  lung. 

Old  Empyema. — Cases  of  inveterate  empyema  loitli  or  loithout  sinus  throw 
much  greater  diflBculties  in  tlie  way  of  the  surgeon's  efforts  to  close  the  cav- 
ity and  fistula  than  recent  cases.  The  retraction  and  consolidation  of  the 
lung,  and  its  envelopment  in  more  or  less  thick  coats  of  pseudo-membrane, 
frustrate  all  attempts  at  closure  of  the  thoracic  cavity.  The  unyielding 
lung  can  not  expand,  while  the  contraction  of  the  partially  yielding  walls 
of  the  thorax,  accomplished  by  lateral  curvature,  by  a  close  crowding  to- 
gether of  the  ribs,  and  a  corresponding  flattening  of  the  affected  side  of  the 
chest,  has  its  limits.  Thus  a  secreting  hollow  space  is  maintained  within 
the  chest  that  can  not  be  obliterated  by  the  unaided  efforts  of  nature,  and 
ultimately  the  patient's  strength  and  life  will  be  sapped.  The  injection  of 
irritating  fluids,  or  the  packing  of  the  cavity  with  strips  of  lint  or  gauze, 
are  of  no  avail,  and  the  only  means  of  effecting  a  cure  is  multiple  exsection 
of  the  ribs  according  to  the  plan  of  Estlander. 

The  rationale  of  this  plan  is  to  do  away  with  the  rigidity  of  the  thoracic 
wall  by  removing  suitably  long  sections  of  as  many  ribs  as  are  found  to  be 
corresponding  to  the  cavity.  Thus  the  limbered  thoracic  wall  may  be 
depressed,  and  can  be  brought  into  actual  contact,  or  nearly  so,  with  the 


DIAGNOSIS  AND  TREATMENT   OF  PHLEGMON. 


243 


Fig.  173. — Cicatrix  in  a  case 
of  Estlander's  operation 
for  inveterate  thoracic  fis- 
tula. (John  Springer's 
case. ) 


opposite  or  pulmonal  surface  of  the 
cavity,  where  it  Avill  be  fastened 
down  and  retained  by  cicatricial 
adhesions  that  will  form  before  the 
reconstruction  of  the  exsected  ribs. 
In  due  course  of  time  the  at- 
tached lung  may  even  regain  a  large 
proportion  of  its  former  functional 
capacity  by  distention  and  aeration, 
and  the  more  or  less  complete  re- 
establishment  of  lung  capacity  is 
manifested  by  the  disappearance  of  lateral  curvature. 

Case  I. — John  Springer,  clerk,  aged  twenty-one.  Em- 
pyema of  left  side  with  thoracic  fistula.  Profuse  secretion 
of  pus,  escaping  through  an  insufficient  incision.  Exten- 
sive burrowing  of  pus  under  latissimus  dorsi  and  serratus 
muscles.  The  process  was  of  one  year's  standing,  and  had 
caused  lateral  curvature  and  far-gone  emaciation.  Aitgust 
S5,  1879. — Incision  and  drainage  of  the  external  abscesses 
and  of  the  left  pleural  cavity  at  the  German  Hospital. 
Exsection  of  the  eighth  rib  became  necessary,  as  the  inter- 
costal space  was  too  narrow  to  permit  of  a  safe  adjustment 

of  the  drainage-tube.  The  operation  brought  on  alarming  collapse,  which  was  over- 
come by  energetic  stimulation.  The  extei-nal  ab- 
scesses healed,  and,  though  the  secretion  from  the 
pleural  cavity  became  much  diminished,  no  tend- 
ency to  a  diminution  of  the  capacity  of  the  sac 
could  be  noticed.  By  New  Year,  1880,  the  pa- 
tient's general  condition  had  become  excellent,  and, 
no  improvement  being  visible  regarding  the  heal- 
ing of  the  thoracic  fistula,  January  3,  1880,  Est- 
lander's operation  was  performed.  By  an  ample 
vertical  incision,  commencing  in  front  of  the  axil- 
lary space  in  the  pectoral  fold,  the  third,  fourth, 
fifth,  sixth,  and  seventh  ribs  were  exposed.  Their 
periosteum  was  slit  up  longitudinally,  and  sections 
of  from  two  to  four  inches  of  the  ribs  were  re- 
moved, the  removed  pieces  being  proportional  to 
the  entire  length  of  the  sevei'al  ribs.  As  soon  as 
the  ribs  were  removed,  the  thoracic  wall  could  be 
well  depressed  into  the  hollow  of  the  cavity.  In 
order  to  retard  the  new  formation  of  bone,  the 
external  wound  was  packed  with  carbolized  gauze, 
and  healed  by  granulation.  The  pleural  hollow 
began  at  once  to  diminish  in  size,  and  April  11, 
1880,  patient  was  discharged  cured.  He  has  re- 
mained well  ever  since  that  time,  and  presented. 
Fig.  174.— Result  after  Estlander's  April  23,  1887,  when  the  accompanying  photo- 
X?iT  spt'!"Tjot"ng;rl;  g'-^Pb^  were  taken,  the  following  status :  A  scarcely 
case.)  noticeable  trace  of  lateral  curvature ;  the  respira- 

33 


244  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

tory  excursions  of  both  sides  of  the  thorax  identical.  All  exsected  ribs  had  re-formed 
and  occupied  a  normal  position.  Eespiratory  murmur  could  be  heard  all  over  the  left 
side  of  the  thorax.     (Figs.  173  and  174). 

Case  II. — Miss  Eva  C  ,  aged  thirteen  and  a  lialf.  Thoracic  fistula  of  two  and  a 
half  years'  duration,  leading  into  a  small  cavity  holding  about  three  ounces  of  fluid, 
tliat  had  resisted  all  efforts  at  cure.  May  13,  1881. — Exsection  of  sixth  and  seventh 
ribs  at  Mount  Sinai  Hospital.  September  20th. — Patient  was  discharged  cured.  In 
August,  1882.  the  healed  fistula  came  open,  with  pain  and  fever.  September  26,  1882. 
— A  sequestrum  two  inches  in  length,  consisting  of  a  portion  of  the  seventh  rib,  was 
extracted.     The  wound  healed  promptly,  and  the  girl's  health  remained  sound. 

The  author's  rather  incomplete  record  of  all  forms  of  empyema  of  chil- 
dren embraces  twenty-two  cases.  All  of  these  recovered  with  the  exception 
of  two — one  died  of  basilar  meningitis  ;  the  other  of  pulmonary  embolism. 

Of  the  nine  cases  of  adults,  four  were  cured  by  simple  incision  ;  two  by 
multiple  excision  of  ribs  ;  one,  a  case  of  perforation  of  a  tubercular  lung 
cavity  into  the  pleura,  died  of  fatal  haemorrhage  into  the  pleura ;  and  two 
cases  were  discharged  improved,  but  not  cured. 

To  conclude,  it  may  be  said  that  the  earlier  the  operation,  the  safer  it  is, 
and  the  better  the  results  achieved  by  it. 

d.  Phlegmon  of  the  Palmar  Aspect  of  the  Hand,  of  the  Arm,  and  Axilla. 
— The  hand,  on  account  of  its  exposed  situation,  is  the  most  frequent  place 
of  small  or  more  serious  injury.  The  necessity  of  the  continned  use  of  a 
slightly  injured  hand,  and  its  contact  with  septic  matter,  lead  to  phlegmo- 
nous affections  of  different  degrees  of  intensity. 

More  serious  traumatisms,  like  incised  or  lacerated  wounds  of  the  hand, 
become  in  numerous  cases  the  seat  of  septic  inflammation,  in  consequence 
of  the  improper  and  uncleanly  primary  treatment  they  receive  from  laymen 
and  some  physicians.  Neglect  of  thorough  cleansing  and  disinfection  of 
a  small  wound  often  leads  to  direful  consequences,  that  perhaps  the  most 
skillful  and  incisive  therapy  can  not  remedy. 

Of  the  manifold  curious  practices  commonly  employed  for  stanching 
hpemorrhage  and  dressing  injuries  to  the  hand,  only  two  may  be  mentioned. 
Fii'.'it  comes  tlte  u.se  of  styptic  solutions.  They  are  unnecessary,  because 
digital  compression  of  short  duration  is  capable  of  stanching  ev^en  profuse 
arterial  hemorrhage. 

The  second  practice  is  the  favorite  closure  of  soiled  wounds  about  the 
hand  with  strips  of  adhesive  plaster  or  a  suture,  loitliout  preceding  disin- 
fection. 

Some  of  tlie  Avorst  forms  of  palmar  phlegmon  observed  by  the  author 
were  due  to  similar  ministrations  by  lay  or  medical  advisers. 

Case  I. — John  McG.,  liquor  dealer,  aged  thirty-nine.  April  30,  1886. — Chopped 
off  the  tip  of  his  index-finger  wnlh  a  hatchet,  and  was  attended  to  immediately  by  a 
medical  quack,  who  strapped  the  injured  part  with  a  structure  of  neatly-arranged 
strips  of  adhesive  plaster  without  previous  cleansing.  The  wound  was  a  smooth  and 
clean-cut  one,  and  offered  the  most  advantageous  conditions  for  the  avoidance  of  infec- 
tion. Severe  pain,  swelling,  and  fever  supervened  on  the  following  day,  but,  at  the 
advice  of  the  medical  attendant,  the  dressing  was  left  on  undisturbed  for  four  days. 


DIAGNOSIS  AXD  TREATMENT  OF  PHLEGMON. 


245 


May  -5,  1886. — The  patient  came  under  the  care  of  the  author,  who  found  the  wound 
and  its  neighborhood  tightly  compressed  by  the  adhesive  strapping,  and  a  phlegmon  of 
the  sheath  of  the  flexor  and  extensor  tendons  of  the  index  extending  into  the  inter- 
muscular planes  of  the  ball  of  the  thumb.  A  number  of  incisions  exposed  the  necrosed 
tendons,  and  resulted  in  a  tardy  cure  after  their  expulsion.  He  was  discharged  cured 
July  10th. 

Case  II. — S.  A.,  laborer,  aged  thirty-five.  Presented  himself  in  January,  1881,  at 
the  German  Dispensary  with  an  incised  wound  of  the  palmar  aspect  of  the  thumb, 
and  an  extensive  subaponeurotic  phlegmon  of  the  palm  and  forearm.  The  hsemor- 
rhage  had  been  unsuccessfully  combated  by  the  patient  himself  with  applications  of 
cobwebs  and  varnish.  Finally,  the  aid  of  a  druggist  was  sought,  who  soaked  a  piece 
of  lint  in  perchloride-of-iron  solution,  and  hermetically  sealed  the  wound  therewith. 
Phlegmon  set  in  promptly,  and  rapidly  extended  to  the  palmar  bursa.  The  styptic 
dressing  remained  undisturbed,  but  the  palmar  swelling  was  treated  with  diligent 
poulticing.  At  the  German  Dispensary  various  incisions  were  done  in  anaesthesia,  fol- 
lowed by  a  tedious  after-treatment  consisting  of  repeated  counter-incisions  until  cure 
was  effected.  The  removal  of  the  styptic  lint,  intimately  matted  together  with  living 
and  necrosed  tissues,  was  exceedingly  troublesome.  The  function  of  the  thumb  was 
partially  restored. 

Dorsum. — On  account  of  the  loose  arraagemeut  of  the  subcutaneous 
connective  tissue  of  the  dorsal  region  of  the  hand,  its  phlegmonous  affec- 
tions present  characteristics  similar  to  those  of  any  other  subcutaneous 
phlegmon.  The  presence  of  a  large  number  of  hair-follicles  farors  the 
localization  of  septic  processes  in  the  cutis,  which  lead  to  the  formation  of 
typical  furuncles  or  rarely  a  carbuncle. 

Palmar  Aspect. — The  peculiar  features  of  the  phlegmonous  processes  of 
the  palmar  aspect  of  the  fingers  and  hand  depend  upon  the  anatomical  pecu- 
liarities of  that  region.     On 


the  fingers  we  find,  instead 
of  tlie  longitudinal  and  loose 
arrangement  of  the  subcu- 
taneous tissue  of  the  dorsum, 
a  dense  net-work  of  short, 
thick  fibers,  inclosing  a  num- 
I)er  of  small  acini  of  fat.  The 
main  direction  of  the  course 
of  these  fibers  is  from  the 
cutis  down  to  the  periosteum, 
or  to  the  slieath  of  the  ten- 
dons, to  which  they  are  close- 
ly attached.  The  direction  of 
the  lymphatics  coincides  with 
that  of  the  connective  tissue. 
Upon  this  centripetal  course 
of  the  lymphatics  depends  the  pronounced  tendency  of  digital  inflamma- 
tions to  penetrate  to  the  bone  or  the  tendons.  The  well-known  tendency 
to  necrosis  and  the  formation  of  cutaneous,  tendinous,  or  osseous  sequestra 
is,  on  the  other  hand,  caused  by  great  tension  due  to  the  rigid  and  dense 


Fig.  175. — Transverse  section  of  terminal  phalanx,  show- 
ing aiTang-ement  and  direction  of  connective-tissue 
fibers.     (From  Vogt.) 


240 


RULES  OF   ASEPTIC   AND  ANTISEPTIC  SURGERY. 


arrangemeut   of  the  subcutaneous 
conneciive  tissue.     (Fig.  175.) 

The  manner  of  the  extension  of 
phlegmonous  inflammation  within 
the  tendinous  sheaths  of  the  pal- 
mar aspect  of  the  hand  is  also  pre- 
scribed by  their  special  arrange- 
ment. Fig.  176  shows  the  sheaths 
of  the  flexors  of  the  thumb  and  lit- 
tle finger  in  open  communication 
with  the  common  palmar  bursa, 
through  which  pass  all  the  flexor 
tendons  of  the  fingers  to  and  un- 
der the  ligamentum  capsi  transver- 
sum,  and  hence  to  the  forearm. 
The  sheaths  of  the  flexors  of  the 
index,  middle,  and  ring  fingers 
represent  separate  and  closed  re- 
ceptacles, which  terminate  on  the 
level  of  the  metacarpo-phalaugeal 
joints.  For  a  short  distance  be- 
yond these  sacs  the  tendons  pos- 
sess no  sheath  proper,  but  are  im- 
mediately inclosed  by  loose  con- 
nective tissue.  We  see  corresjiond- 
ing  to  these  three  closed  sacs  three  pointed  extensions  of  the  common  pal- 
mar bursa,  into  which  the  tendons  enter 
after  passing  through  the  sheathless  part 
of  their  course.     (Figs.  176  and  177.) 

Thumb  and  Little  Finger. — Upon 
this  arrangement  is  based  the  great  im- 
port of  the  suppurations  of  the  thumb 
and  little  finger,  mentioned  by  the  old- 
est medical  writers,  and  well  known  to 
the  common  people.  While  gatherings 
of  the  index,  the  middle,  and  ring  fin- 
gers often  perforate  s])ontaneously  near 
or  on  the  level  of  the  finger-balls  (where 
the  blind  end  of  the  closed  tendinous 
sheath  coincides  with  the  thinnest  por- 
tion of  the  palmar  aponeurosis),  suppu- 
rations of  the  thumb  and  little  finger  are 
very  apt  to,  and  as  a  matter  of  fact  often 
do,  extend  at  once  into  the  palmar  bursa. 
The  knowledge  of  this  peculiarity  is  of 
the  greatest  practical  importance. 


Fig.  176. — a,  Blind  endings  of  sheaths  of  the  in- 
dex, middle,  and  ring  fingers,  b,  c.  Sheaths  of 
thumb  and  little  finorer  openly  communicating 
with  palmar  burr^a.     (From  Vogt.) 


% 


/ 


Fir,.  177. — Common  palmar  bursa  injected, 
and  showing  extensions  toward  thumb 
and  little  fineer.     (  From  Vo^t. ) 


DIAGNOSIS  AND  TEEATMENT  OF  PHLEGMON.  247 

Aside  from  the  acuteness  of  the  symptoms,  phlegmonous  affections 
located  on  the  palmar  aspect  of  the  hand  and  fingers  present  some  jiecu- 
liarities,  the  diagnostic  significance  of  which  must  be  mentioned.  Redness 
of  the  shin  is  generally  absent,  to  appear  only  when  the  process  has  worked 
its  way  uj)  to  the  skin.  Oedema  is  moderate,  and  is  often  overlooked  by  in- 
experienced observers,  who  are  misled  by  the  oedema  and  redness  of  the  dor- 
sal soft  parts  to  look  there,  and  not  on  the  palmar  side,  for  the  focus  of  the 
disturbance. 

The  subjective  symptoms  are  very  distressing,  high  fever  and  intense 
pain  being  the  rule. 

Treatment. — Prevention  of  phlegmon  by  guarding  against  the  infection 
of  large  or  small  injuries  of  the  integument  is  very  profitable.  Small 
excoriations  and  shallow  cuts  should  be  cleansed  and  touched  with  acetic- 
acid.  Punctures  should  be  well  sucked  and  bled  and  sealed  with  an  acetic 
acid  eschar  ;  or,  if  there  be  the  least  suspicion  of  infection  by  an  unclean 
sharp-pointed  object,  dilatation  of  the  small  hole,  thorough  wiping  out  of 
the  track  with  sublimate  lotion,  and  drainage  by  means  of  a  few  short  pieces 
of  catgut  laid  into  the  bottom  of  the  puncture  are  to  be  employed.  Li  this 
latter  class  of  cases  a  moist  dressing  is  appropriate. 

In  the  presence  of  an  inflammation  that  is  evidently  gathering  mo- 
mentum, all  attempts  at  an  abortive  treatment  are  risky,  as  the  deceptive 
relief  afforded  by  hot  ap]3lications  is  very  apt  to  induce  patient  and  physician 
to  be  tardy  with  the  application  of  the  best  and  surest  antiphlogistic  :  the 
knife.  By  the  time  that  the  unbearable  suffering  finally  compels  energetic 
treatment,  suppuration  requires  a  long  incision,  and  necrosis  of  a  phalanx 
or  tendon  may  be  established.  At  first  it  might  have  teen  prevented  by  a 
much  smaller  incision — in  fact,  hy  a  mere  puncture.  The  cases  where  a 
timely  deep  puncture  with  a  tenotomy  knife  released  one  or  a  few  drops  of 
pus  to  the  most  intense  relief  of  the  patient  were  very  numerous  in  the 
author's  dispensary  experience,  and  he  can  not  recommend  this  truly  con- 
servative procedure  in  warm  enough  terms.  Instead  of  a  terribly  painful  and 
tedious  illness  ending  in  more  or  less  of  destruction,  rapid  healing  of  the 
small  wound  under  the  moist  dressing  will  be  the  rule.  And,  if  we  consider 
that  local  anaesthesia  by  cocaine  or  the  ether  spray  (both  more  effective  if 
combined  with  artificial  angemia)  has  deprived  incision  of  all  its  terrors, 
hesitation  and  poulticing  become  a  culpable  offense  against  the  dictates  of 
common  sense. 

The  diagnosis  of  the  exact  locality  of  beginning  suppuration  is  easily 
made  by  the  aid  of  the  unmistakable  sensations  of  the  patient.  Gentle 
pressure  by  a  probe  upon  different  points  of  the  affected  region,  made  to 
cover  successively  and  in  a  methodical  way  the  entire  area  in  the  shape  of  a 
spiral,  will  soon  detect  the  most  painful  spot.  If  one  or  two  repetitions  of 
this  process  confirm  the  result  of  the  first  search,  no  hesitation  need  be  felt. 
The  point  thus  found  is  marked  by  a  shallow  scratch  or  otherwise,  the 
finger  or  hand  is  anaesthetized,  and  the  tenotomy  knife  is  boldly  thrust 
down   to  the  periosteum.      If   a  few  drops  of  pus  escape  only,   this  will 


248 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


siiflHce  ;  if  more,  the  ])uncturc  should  be  at  once  proportionately  enlarged, 
thoroughly  irrigated,  and  covered  with  a  moist  dressing.  As  the  affection 
generally  extends  to  the  periosteum  or  tendon,  the  incision  should  always 
be  carried  down  to  one  or  the  other,  and  should  be  longitudinal  to  avoid 
injury  of  vessels  or  tendons. 

Subfascial  phlegmons  of  the  palm  should  be  also  promptly  and  suffi- 
ciently incised.     The  adjoining  diagram  (Fig.  178)  will  be  found  very  useful 

in  pointing  out  the  small  area  which  should 
be  avoided  on  account  of  the  superficial  pal- 
mar arch.  It  is  situated  between  the  first 
and  last  strokes  of  the  capital  M  that  marks 
the  palm.  After  the  aponeurosis  has  been 
cut  through,  any  point  of  the  jialm  can  be 
reached  from  the  lines  marked  out  on  Fig. 
178,  by  Hilton-Eoser's  method. 

Incision  is  advisable  even  at  the  risk  of 
cutting  the  palmar  arch,  as  the  haemorrhage 
thus  caused  can  be  easily  stopped  by  ligatur- 
ing the  vessel  in  an  ample  incision,  and  Es- 
march's  band  will  effectively  prevent  undue 
loss  of  blood  during  the  operation. 

There  is  no  region  of  the  human  body 
where  senseless  poulticing  of  phlegmons  has 
done  more  harm,  and  timely  incision  can  do 
more  good,  than  in  the  palm. 

Case. — M.  M.,  saddler,  a^ed  sixty-five,  had  in 
the  latter  part  of  August,  1885,  a  boil  of  the  face, 
which  he  was  in  the  habit  of  dressing  himself.  At 
the  same  time  he  infected  a  small  scratch  of  liis 
right  forefinger,  from  which  developed  a  felon.  The 
family  attendant  ordered  poulticing,  which  was  Icept 
lip  uninterriij)tedly  for  more  than  three  iceelcs.  Not  one  incision  had  been  7nade,  and 
when  the  author  saw  the  patient,  September  28,  1885,  about  twenty-four  hours  before 
his  death  from  septicaemia,  the  hand  and  entire  arm  presented  a  terrible  condition  of 
phlegmonous  destruction.  Not  one  tendon,  no  joint,  was  free  from  suppuration,  and 
a  number  of  phalanges  were  necrosed  ;  the  skin  was  extensively  detached  and  repre- 
sented a  boggy  bag,  from  which  pus  flowed  copiously  through  a  number  of  smaller 
and  larger  defects  due  to  sloughing.  Diplitheria  of  the  throat,  tongue,  and  mouth  had 
also  developed  the  day  before  the  consultation,  and  the  wretched  general  condition  of 
the  patient  put  any  operative  measure  out  of  question.  The  inquiry,  liow  such  a  state 
of  things  could  come  about,  drew  the  reply  that  "  there  were  plenty  of  openings,  they 
seemed  to  discharge  f reel i/  and  nicely,  and  therefore  surgical  interference  was  refrained 
from." 

Neglected  cases,  where  the  suppurative  process  has  attained  wide  pro- 
portions, should  be  treated  on  general  principles  laid  down  regarding  the 
management  of  complicated  abscesses.  All  recesses  should  be  found  out, 
separately  incised,  and  drained.     Where  in  the  course  of  a  long-continued 


U  R 

Fig.  178. — Straight  lines  marking 
the  places  where  incision.^  can  be 
safely  made.  The  space  between 
the  first  and  last  strokes  of  the 
capital  M,  markiuir  the  palm, 
should  be  avoided.     (From  \  ogt.) 


DIA&NOSIS  AND  TEEATMENT  OF  PHLEGMON. 


249 


process  the  soft  tissues  have  been  more  or  less  permeated  by  the  septic 
poison,  and  multiple  small  abscesses  with  a  sanious  discharge  have  estab- 
lished themselves,  the  enormous  swelling  will  render  efficient  drainage  very 
difficult  or  even  impossible. 

Vertical  suspension  on  Volkmann's  arm-splint  tvith  continuous  irriga- 
tion will  often  do  here  very  effective  service.     Its  detail  is  as  follows  : 

After  the  proper  incisions  are  made  and  the  requisite  number  of  drainage- 
tubes  have  been  inserted,  the  arm  is  enveloped  in  gauze,  is  loosely  attached 
to  the  splint  (Fig.  179)  by  a  roller  bandage,  and  is  suspended  from  the  ceil- 
ing or  a  suitable  frame.  One  or  more  irri- 
gators filled  with  a  very  weak  sublimated  or 
salicylated  lotion  being  also  suspended,  their 
nozzles  are  connected  with  one  or  more  of  the 
uppermost  drainage-tubes.  A  rubber  blanket 
is  so  arranged  beneath  the  suspended  limb  as 
to  catch  all  the  drippings  and  to  conduct 
them  into  a  bucket  placed  alongside  the  bed. 
The  flow  of  the  irrigating  fluid  is  regulated 
by  pushing  a  match-stick  or  a  straw  into  the 
nozzle  of  the  irrigator.  In  this  manner,  ac- 
cording to  necessity,  a  free  current  or  the 
escape  of  the  fluid  in  drops  can  be  effected. 

If  the  entire  limb  require  irrigation,  the 
use  of  many  irrigators  can  be  obviated  by  a 
simple  contrivance  recommended  by  Starcke. 
A  tin  tube,  open  at  one  end,  and  provided 
with  a  number  of  nipples,  is  connected  with 
a  large  irrigator.  On  the  ni^Dples  rubber  tubes 
are  slipped,  and  are  conducted  to  the  several 
drainage-tubes,  with  which  connection  is  es- 
tablished through  short  pieces  of  glass  tubing. 
(Fig.  180.) 

Continuous  immersion  in  a  weak  antisep- 
tic lotion  is  a  very  simple  and  effective  sub- 
stitute for  permanent  irrigation,  although  it 
precludes  the  advantages  of  vertical  suspen- 
sion. The  lotion  should  be  changed  from 
three  to  four  times  daily,  and  its  tempera- 
ture is  to  be  regulated  by  the  patient's  sen- 
sations.    Some  will  have  it  warm,  others  will 

prefer  a  cool  bath.  By  placing  one  or  two  alcohol  lamps  underneath  the 
tin  vessel  containing  the  bath,  an  even  temperature  can  be  maintained. 

Case  I. — Hugo  B.,  laborer,  aged  twenty-eight,  admitted,  March  11,  1886,  to  the 
German  Hospital  with  extensive  phlegmon  of  the  palm,  consequent  npon  an  injury  to 
the  middle  finger.  The  corresponding  metacarpo-phalangeal  joint  was  destroyed.  The 
house-surgeon  exarticulated  the  third  finger,  and  made  a  number  of  incisions  in  the 


Fig.  179 


Volkmann's  arm-splint 
for  vertical  suspension. 


250 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


palm,  liberating  a  good  deal  of  pus.  By  March  12th  the  temperature  had  been  some- 
what lowered,  but  an  ominous  swelling  of  the  forearm  appeared.  March  18th. — A 
number  of  incisions  were  made  on  the  flexor  side  of  the  arm  into  the  suppurating 

tendinous  sheaths.     Moist  dressings  and  elevated 
posture.      Continuous  high  fever.      March  S5th. — 
Renewed  incisions  on  dorsum  of  forearm,  exposing 
the  extensor  tendons.    Swelling  of  the  arm  and  axil- 
lary glands.     High  fever.    TJie  affection  proving  un- 
controllable,  on   account  of  the  uniform   purulent 
infiltration  of  the  soft  tissues,  continuous  immersion 
of  the  limb  in  a  1  :  5,000  solution  of  corrosive  sub- 
limate was  resorted  to,  and  was  constantly  employed 
during  the  montlis  of  April  and  May.    No  mercurial 
toxic  symptoms  wiiatever  could  be  observed  during 
this  period  of  time.     The  swelling  of  the  axillary 
glands  disappeared  a  few  days  after  the  commence- 
ment of  this  treatment,  and  a  tardy  disappearance 
of  the  febrile  symptoms  followed  pari  passu  with 
the  detachment  of  a  number  of  gangrenous  muscles 
and  tendons.    Toward  the  end  of  May  all  the  sloughs 
were  detached,  and  the 
little  finger  was  removed 
on  account  of  necrosis  of 
the   phalanges.      During 
June  and  July  a  number 
of  small  abscesses  devel- 
oped  on   the    hand   and 
along  the  arm,  and  were 
successively  incised.  End 
of  July  all  incisions  were 
healed.     Active  and  pas- 
sive motions  and  massage 
restored    a    part   of  the 
motion  of  the  wrist,  the 
thumb,  and  index.     The 
patient,  of  whose  limb  and  life  we  had  despaired,  was  discharged  cured  and  in  a 
florid  condition  August  20th. 

Case  II. — A.  W.,  laborer,  aged  thirty-two,  admitted,  August  17,  1886,  to  German 
Hospital.  August  7th. — Sustained  an  injury  of  the  left  forearm.  The  profuse  hsem- 
orrhage  was  stopped  with  a  tourniquet.  The  physician  left  this  instrument  in  situ, 
and  ordered  to  tighten  the  screw  in  ease  of  renewed  loss  of  blood.  The  patient,  fol- 
lowing tlie  advice  of  his  physician,  tightened  the  tourniquet  as  directed.  August  9th. 
— The  forearm  swelled  up  considerably,  and  assumed  a  bluish  cast;  at  the  same  time 
several  chills  and  high  fever  set  in.  Increasing  swelling.  A  homoeopathic  practitioner 
of  Newark  made  a  few  superficial  incisions,  and,  seeing  no  improvement  therefrom, 
proposed  amputation.  On  admission  the  patient  presented  a  pitiable  condition  of  sep- 
tieaeniia.  Temperature,  105'8°  Fahr.  The  pulse  was  hardly  noticeable,  respiration 
very  frequent,  tlie  patient  cyanosed  and  somnolent,  liis  body  covered  with  cold  per- 
spiration. The  entire  left  arm  was  enormously  swollen,  the  skin  of  the  forearm  exten- 
sively discolored,  and  fluctuation  was  noted  in  many  places.  On  account  of  the  collapsed 
condition  of  the  patient,  only  a  few  incisions  were  made  to  relieve  the  pus  and  to  reduce 


Fig.  180. — Continuous  irrigation  by  means  of  Starcke's  tube,  in 
vertical  suspension. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  251 

tension.  Aside  from  the  large  abscesses,  a  uniform  ■purulent  infiltration  of  the  tissues 
was  found.  August  18th. — Nuuierous  incisions  were  made  in  anaesthesia,  the  entire 
forearm  exhibiting  a  state  of  ichorous  inliltration.  Necrosed  portions  of  the  skin  and 
of  various  muscles  were  ablated,  and  a  number  of  drainage-tubes  were  inserted.  The 
arm  was  kept  continuously  immersed  in  a  tepid  bath  for  four  days  without  an  appreci- 
able improvement  of  the  local  or  general  disturbance.  August  SOth. — The  arm  was 
vertically  suspended,  and  continuous  irrigation  by  a  weak  mei'curial  lotion  was  estab- 
lished and  kept  up  until  September  18tli.  This  change  was  followed  by  slow  but 
unmistakable  improvement,  interrupted  by  occasional  rises  of  temperature  due  to 
retention.  The  entire  integument  of  the  volar  side  of  the  arm  was  lost  by  necrosis, 
and  the  defect  had  to  be  covered  by  a  number  of  skin-grafts.  The  patient  was  dis- 
charged cured  November  29th,  with  slight  mobility  of  the  wrist  and  the  metacarpo- 
phalangeal joints. 

By  these  means  many  a  limb  can  be  saved.  The  detachment  of  slough- 
ing tissues  should  be  facilitated  by  the  use  of  scissors  and  forceps,  and  the 
rule  should  be  upheld  not  to  sacrifice  any  part  of  the  hand  that  is  viable. 
Even  the  most  sorry-looking,  shapeless,  and  immovable  rudiments  of  this 
useful  organ  will  be  of  great  value  to  the  patient  afterward. 

Should  all  these  means  be  of  no  avail  in  checking  the  progress  of  sup- 
puration, amputation  will  have  to  be  considered  as  a  last  life-saving  remedy. 

Case. — Ernst  B.,  shoemaker,  aged  sixty-nine.  Had  been  for  years  attended  to  at 
the  German  Dispensary  for  a  chronic  fungous  affection  of  the  wrist.  In  the  fall  of 
1885  a  phlegmonous  inflammation  started  from  one  of  the  many  fistulse  present,  grad- 
ually involving  the  entire  hand,  wrist,  and  part  of  the  forearm.  A  large  number  of 
incisions  had  been  made,  but  the  trouble  crept  steadily  from  one  joint  to  another, 
and  along  the  tendons,  until  the  hand  presented  one  swollen,  shapeless,  festering  mass. 
Felriiary  13.  1886. — Amputation  of  the  forearm  was  done  at  its  upper  third.  Primary 
nnion  followed  throughout. 

Joints  of  the  Upper  Extremity. — Injury  and  infection  of  the  metacarpo- 
phalangeal or  first  interphalangeaJ  joints  frequently  take  place  during  a 
rough-and-tumble  fight,  when  the  fist  of  a  fighter  hits  the  incisors  of  his 
antagonist.  The  author  has  treated  four  cases  of  this  kind  within  the  last 
seven  years.  In  one,  syjjhilis  followed  a  very  obstinate  suppuration  of  the 
first  interphalangeal  joint  of  the  right  index. 

But  often  enough  secondary  suppuration  of  the  finger-joints  is  caused  by 
extension  of  a  neglected  subcutaneous  or  tendineal  phlegmon. 

Note. — A  very  acute  phlegmon  of  the  elboiv-joint  came  under  the  observation  of  the  author 
at  Mount  Sinai  Hospital.  A  compound  dislocation  was  freshly  admitted,  and  was  reduced  and 
dressed  so-called  "  antiseptically  "  by  a  junior  member  of  the  house  staff.  Suppuration  followed 
promptly,  the  sutures  had  to  be  removed,  a  number  of  incisions  had  to  be  made,  and  a  tardy 
cure  was  effected,  resulting  in  bony  anchylosis  of  the  elbow  at  an  acute  angle.  (See  case  of 
Samuel  Krongold,  page  207.) 

Suppuration  of  the  finger-joints  usually  terminates  in  anchylosis.  In 
many  cases  this  untoward  result  can  be  prevented  by  exsection  and  subse- 
quent careful  treatment  by  passive  and  active  movements.  However,  this 
operation  should  never  he  undertaken  before  the  phlegmonous  process  has 
terminated,  and  suppuration  has  assumed  a  bland  character.     The  author's 

34 


252  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

results  achieved  by  this  little  operation  are  very  satisfactory,  and  the  jiro- 
cedure  can  be  warmly  recommended.  As  a  rule,  a  more  or  less  movable 
Joint  results,  which  certainly  is  preferable  to  a  stiff  finger.  In  one  case 
double  exsection  was  successfuUy  done  after  a  felon  of  the  thumb,  involving 
the  metacarpo- phalangeal  and  interphalangeal  joints.  To  this  end,  how- 
ever, preservation  of  the  tendons  is  a  necessary  condition. 

Case  I. — Frank  P.,  liquor  dealer,  aged  thirty-six.  Seen  January  15,  1885,  with 
Dr.  H.  Balser,  on  account  of  a  phlegmon  of  tlie  right  index  and  palm,  caused  by  open 
injury  to  the  metacarpo-phalangeal  joint.  The  injury  was  sustained,  January  1,  1885, 
during  a  fight  by  violent  contact  with  the  antagonist's  teeth.  The  process  had  lost  its 
virulent  character,  and  subperiosteal  exsection,  by  two  lateral  incisions,  was  done 
January  l(ith.  The  cure  was  uninterrupted.  The  flexor  profundus  tendon  had  sloughed 
away,  hence  only  the  first  phalanx  could  be  actively  bent.  Patient  discharged  cured 
February  22.  1885. 

Case  II. — S.  L..  baker,  aged  twenty-nine.  Seen  in  December,  1882,  in  consulta- 
tion with  Dr.  H.  Kudlich.  Recent  phlegmon  of  thumb,  suppuration  of  tendineal 
sheath  of  flexors  and  of  both  the  joints  of  the  thumb.  Lecemler  12th. — Three  in- 
cisions released  the  tension.  After  the  cessation  of  the  acute  stage  of  the  inflamma- 
tion, December  29th,  exsection  of  metacarpo-phalangeal  and  interphalangeal  joints 
was  done.     Uninterrupted  cure ;  good  function  preserved. 

Phlegmon  of  the  olecranic  bursa  is  characterized  by  very  acute  local  and 
general  disturbance  due  to  the  great  tension  maintained  by  the  dense  cap- 
sule of  the  sac.  Free  incision  supplemented  by  Volkmann's  punctuation 
of  the  infiltrated  skin  of  the  vicinity  is  promptly  followed  by  relief  and  a 
rapid  cure. 

Siqjpiiration  of  the  cubital  or  axillary  lymphatic  glands  is  a  very  com- 
mon complication  of  limited  or  extensive  septic  inflammatory  processes  af- 
fecting the  hand  and  arm. 

Ttvo  forms  of  suppuration  have  to  be  distinguished:  One  of  an  acute  char- 
acter, terminating  in  the  formation  of  one  more  or  less  extensive  abscess, 
the  result  of  confluence  of  several  foci.  A  spontaneous  or  artificial  evacua- 
tion generally  leads  to  rapid  cure. 

Another  more  chronic  and  very  obstinate  form,  in  which  a  group  of 
lymphatic  glands  is  attacked  in  succession,  leading  to  the  formation  of  a 
series  of  deep-seated  abscesses  and  a  number  of  sinuses.  This  form  is  gener- 
ally observed  in  poorly-nourished  subjects.  The  individuality  of  the  glands 
is  not  destroyed  rapidly  as  in  the  more  acute  form,  but  their  slow  and 
gradual  destruction  is  accomplished  by  a  tedious  ulcerative  process.  Long 
before  the  glandular  ulceration  is  terminated,  cicatricial  contraction  of  the 
sinuses  leading  through  healthy  tissues  will  occur,  and  cause  retention. 
This  is  followed  by  an  exacerbation  of  the  local  and  general  symjitoms,  and 
results  in  the  formation  of  a  new  abscess  and  sinus.  The  interminable 
suppuration  often  leads  to  serious  deterioration  of  the  general  condition, 
marked  by  emaciation,  night-sweats,  and  loss  of  appetite.  As  these  cases 
represent  an  aggregation  of  a  large  number  of  septic  foci  imbedded  in  dense 
tissue,  one  or  even  more  incisions  will  not  be  adequate  for  efficient  drainage, 
and  in  spite  of  them  the  process  will  continue. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  253 

Extirpation  of  the  entire  group  of  affected  lymph-glands  by  careful 
preparation  is  their  best  therapy.  As  rupturing  of  one  or  more  of  the 
broken-down  glands,  and  soiling  of  the  wound  by  their  contents,  can  not 
always  be  avoided,  closure  by  sutures  is  best  omitted.  Thorough  irrigation 
with  corrosive-sublimate  lotion,  a  loose  packing  with  moist  gauze,  and  a 
moist  dressing  are  appropriate. 

Case  I. — Emma  Epple,  servant,  aged  seventeen.  Admitted  to  German  Hospital 
March  31,  1886.  As  the  consequence  of  a  "run-around"  treated  by  poulticing,  sup- 
puration of  the  lymphatic  glands  of  the  left  axilla  developed.  The  arm-pit  was  filled 
with  a  densely  infiltrated  large  mass  of  intuniescent  and  very  painful  glands.  The 
continuous  fever  and  sleeplessness  had  produced  an  alarming  degree  of  anasmia  and 
■debility,  characterized  by  night-sweats  and  loss  of  appetite.  As  no  fluctuation  could 
be  made  out,  and  presumably  all  the  affected  glands  were  in  a  state  of  suppuration, 
extirpation  of  the  entire  glandular  mass  was  advised,  and  carried  into  effect  April  3d. 
Dissection  of  the  tumor  from  the  axillary  vessels  was  rather  difficult,  and,  one  of  the 
tenacula  lacerating  one  of  the  brittle  glands,  a  few  drops  of  pus  exuded  into  the 
-wound.  After  thorough  irrigation  with  corrosive-sublimate  solution,  the  wound  was 
closed  by  suture,  and  an  antiseptic  moist  dressing  was  applied.  Previous  to  this  a  sepa- 
rate incision  was  made  at  the  most  dependent  portion  of  the  cavity  for  the  reception  of 
a  stout  drainage-tube.  A  sharp  chill  and  much  pain  followed  the  next  day  after  the 
operation.  Undoubtedly,  infection  of  the  cavity  by  contact  with  the  escaped  pus  had 
taken  place.  The  dressings  being  removed,  pus  was  seen  oozing  out  of  the  drainage- 
tube.  Daily  change  of  dressings  and  irrigation  of  the  cavity  with  mercurial  lotion  was 
followed  by  rapid  improvement,  and  the  patient  was  discharged  cured,  May  Yth. 

Case  II. — 0.  H.,  butcher,  aged  sixty-two.  Slightly  cut  the  dorsum  of  his  left 
middle  finger,  October  15,  1885,  with  a  butcher-knife.  A  phlegmon  developed,  and 
was  treated  by  the  patient  himself  with  poulticing  till  October  27th,  when  spontaneous 
■evacuation  took  place.  For  a  few  days  previous  to  this  date,  intumescence  of  the  cu- 
I)ital  lymphatic  glands  was  noted.  Octoler  28th. — The  patient  came  under  the  author's 
•care  with  an  angry  swelling  of  the  region  of  the  cubital  glands.  Incision  was  proposed 
and  declined.  After  a  couple  of  wretched  nights  the  patient  consented  to  incision, 
which  was  done  under  chloroform,  October  31st.  A  small  amount  of  pus  came  away, 
and  a  drainage-tube  and  moist  dressings  were  applied.  The  momentary  improvement 
soon  gave  way  to  renewed  attacks  of  pain  and  swelling,  apparently  due  to  succes- 
-sive  suppuration  of  several  glands.  Much  difficulty  was  experienced  in  keeping  the 
drainage-tube  in  situ,  the  external  wound  showing  a  great  tendency  to  cicatrization, 
while  the  slow  ulceration  of  the  glandular  tissue  was  still  progressing.  An  extirpation 
•of  the  glandular  mass  would  have  been  more  serviceable  in  this  case  than  a  simple 
incision.  After  a  tedious  and  troublesome  course  of  treatment,  the  case  was  finally 
■discharged  cured,  December  27th. 

e.  Suppurative  Affections  of  the  Lower  Extremity : 

(a)  Ingkown  Toe-JSTail. — The  most  common  cause  of  this  distressing 
affection  is  the  improper  care  of  the  toe-nails.  Sweating  feet,  in  combina- 
tion with  lack  of  cleanliness,  improperly  trimmed  toe-nails,  and  narrow-toed 
shoes,  offer  the  best  conditions  for  the  development  of  ulcerative  processes 
near  the  anterior  edge  of  the  nail.  Whenever  the  nail  is  trimmed  off  too 
short,  the  adjacent  skin  will  overlap  its  angle  (Fig.  181).  The  epidermis  be- 
ing macerated  and  soft  from  the  profuse  sweating,  a  small  amount  of  friction 
between  the  edge  of  the  nail  and  the  skin  will  be  sufficient  to  cause  an  exco- 


254 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


Fig.  181. — a,  Wronij  way  of  trimming 
toe-nail,     b,  The  right  way. 


riation.  The  pyogenic  germs,  so  abundantly  present  in  the  fetid  epidermidal 
masses  of  sweating  feet,  will  not  only  come  in  contact  with  the  raw  surface, 
but  will  be  rubbed  into  the  open  lymphatics  by  each  successive  step  taken  by 

the  individual.  An  ulcerative  inilani- 
mation  of  the  parts  will  result,  which 
offers  poor  conditions  for  natural  drain- 
age. Retention  of  the  septic  secretions 
leads  to  chronic  suppuration,  and  to 
the  extension  of  the  process  backward 
toward  the  root  of  and  also  under  the 
nail,  until  more  or  less  of  it  becomes 
undermined  and  detached.  Exuberant 
granulations,  subject  to  frequent  ulcer- 
ative destruction,  spring  up  from  the 
hyi^ertrophied  and  infiltrated  overlap- 
ping skin,  and,  if  unchecked,  the  disorder  terminates  in  the  loss  of  the  nail. 
Occasionally  an  ingrown  toe-nail  is  the  starting-point  of  phlegmon  or  ery- 
sipelas of  the  dorsum  of  the  foot.  The  initial  stages  of  the  mischief  can 
often  be  successfully  met  with  careful  local  treatment.  Disinfecting  baths, 
sprinkling  of  alum  and  salicylic  powder  (alum,  usti,  |  ij  ;  acidi  salicyl., 
^  ss ;  bismuthi  subnitr.,  |  ijss)  into  the  stockings,  which  should  be  daily 
changed,  and  the  packing  of  salicylated  or  iodoformed  cotton  or  a  small 
piece  of  heavy  tin-foil  under  the  edge  of  the  nail,  frequently  result  in  alle- 
viation, if  not  a  cure,  of  the  affection. 

More  inveterate  or  extensive  cases  in  persons  unable  to  devote  the  neces- 
sary care  and  time  to  the  treatment  of  this  trouble  will  be  best  cured  by 
operation.  After  careful  scrubbing  and  disinfection,  the  toe  is  rendered 
anaemic  by  constriction  of  its  root  with  a  piece  of  rubber  tubing.  Local 
anaesthesia  is  produced  by  either  an  injection  of  a  cocaine  solution  or  the 
use  of  Richardson's  ether-spray.  The 
point  of  a  bistoury  is  (Fig.  183) 
placed  against  the  exuberant  tissues 
adjoining  the  nail,  and  is  thrust 
through  the  margin  of  the  toe.  It 
is  carried  forward  until  the  integu 
ment  is  separated  in  the  shape  of  a 
longitudinal  flap.  Then  the  knife 
is  reversed  and  carried  back  well  be- 
yond the  matrix  of  the  nail,  where 
the  flap  (c)  is  cut  off. 

The  pointed  blade  of  a  straight 
pair  of  scissors  is  placed  under  the  an- 
terior margin  of  the  nail  (Fig.  182,  A,  b)  just  beyond  the  limit  of  the  disease, 
and,  being  thrust  under  it,  cuts  through  the  nail  in  an  autero-posterior  direc- 
tion well  back  of  the  matrix.  One  blade  of  a  stout  pair  of  dressing-forceps  is 
next  insinuated  into  the  slit  in  the  nail  and  under  the  loose  segment.     This, 


Fig.  18^. — Operation  for  ingrown  toe-nail. 
A,  B,  Line  of  section  through  the  nail 
and  matri.x. 


DIAGNOSIS  AND  TEEATMENT  OF  PHLEGMON.  255 

being  firmly  grasped,  is  evulsed  with  an  outward  rotating  motion.  Good 
care  must  be  taken  not  to  leave  behind  any  shreds  of  the  cut-off  matrix. 
Any  granulations  are  scraped  away  with  a  sharp  spoon,  and  the  wound  is 
well  irrigated  with  mercuric  lotion.  A  strip  of  rubber  tissue  well  soaked 
in  carbolic  lotion,  aud  just  large  enough  to  cover  the  wound,  is  placed  next 
to  it ;  over  this  comes  a  strip  of  iodoformed  gauze  and  a  small  disinfected 
sponge,  the  latter  to  exercise  elastic  pressure  for  the  prevention  of  undue 
haemorrhage  ;  finally  comes  a  light,  compressive  moist  dressing,  fastened 
by  a  roller  bandage.  While  the  patient's  foot  is  held  elevated,  the  rubber 
band  is  removed.  The  first  dressing  can  be  left  on  for  a  week  or  even  two 
weeks.  Being  moist,  it  will  peel  off  easily  when  removed,  aud,  accordiug 
to  its  size,  the  wound  will  be  found  either  partly  or  entirely  cicatrized  over. 
Care  must  be  taken  not  to  compress  the  toe  too  much,  as  necrosis  of  the 
skin  by  pressure  may  develop  and  retard  the  healing. 

The  author  has  treated  several  hundred  of  these  cases  in  the  manner  de- 
scribed with  the  best  results,  the  majority  being  patients  of  the  German 
Dis]oensary,  who  walked  to  and  from  the  institution  during  the  time  of 
treatment. 

(5)  Chhoxic  Ulcers  of  the  Leg. — Neglected  excoriations  or  abrasions 
of  the  skin  belonging  to  the  lower  third  of  the  leg  are  the  most  common 
starting-point  of  ulcerous  processes.  Varices  due  to  stagnation  of  the  venous 
circulation  render  the  progressive  invasion  of  new  areas  of  tissue  by  micro- 
cocci, ever  present  in  the  putrescent  discharges,  especially  easy.  Conse- 
quently, ulcerative  destruction  develops.  The  successful  treatment  of  this 
condition  must  be  based  upon  an  elimination  of  the  causal  factors.  Pre- 
vention or  elimination  of  decomposition  by  antiseptics,  and  an  improve- 
ment of  the  circulatory  conditions  by  elevation  of  the  limb  or  its  elastic 
compression,  form  the  cardinal  points  of  our  therapy. 

The  affected  limb  is  carefully  cleansed  with  soap  and  a  soft  flannel  rag 
until  all  the  crusts  of  inspissated  secretion  and  epidermis  are  removed.  This 
process  will  be  greatly  facilitated  by  packing  of  the  parts  in  strips  of  lint 
saturated  with  vaseline  or  unsalted  lard  the  night  previous  to  the  cleansing 
bath.  Plain  water  should  never  be  used  on  account  of  its  irritating  quali- 
ties and  its  liability  to  cause  eczema.  After  the  bath  the  soap-suds  should 
be  simply  wiped  off  with  a  soft  toweL  The  ulcer  is  well  mopped  with  a 
1  :  1,000  solution  of  corrosive  sublimate,  or,  where  the  stench  is  very  intense, 
with  a  4  :  1,000  solution  of  permanganate  of  potash.  Iodoform  powder  is 
dusted  over  the  ulcer,  and  a  suitable  patch  of  rubber  tissue  is  placed  next 
to  it.  The  eczematous  skin  in  the  vicinity  is  well  anointed  with  vaseline 
or  an  astringent  salve,  and  a  regular  antiseptic  dressing  is  snugly  bandaged 
on  to  the  ulcer,  the  roller  bandage  extending  from  the  toes  to  the  knee-joint. 
This  dressing  need  not  be  removed  before  two  or  three  days,  the  frequency 
of  renewal  being  dependent  upon  the  quantity  of  the  discharge.  As  soon 
as  cicatrization  is  well  advanced,  a  simpler  dressing,  consisting  of  a  strap- 
ping of  mercurial  plaster  covered  with  a  pad  of  absorbent  cotton,  held  down 
by  a  Martin's  elastic  bandage,  can  be  substituted  therefor,  and  the  patient 


256  EULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

may  be  permitted  to  abandon  the  recnmbent  posture  and  take  moderate 
exercise.  When  cicatrization  is  completed,  a  well-cleansed  elastic  bandage 
will  suffice  to  prevent  renewed  ulceration.  It  is  most  convenient  to  have 
two  elastic  bandages,  to  be  worn  alternatingly.  Under  this  simple  treatment 
most  ulcers  of  the  leg,  even  those  surrounded  by  callous  edges,  will  develop 
healthy  granulations,  and  will  heal  kindly.  Due  regard  should  be  paid  to 
the  general  condition  of  the  patient,  as  on  it  may  depend  to  a  great  measure 
the  rapidity  of  the  cure.  A  marastic  state  of  the  system  should  be  improved 
by  suitable  nutritious  diet ;  the  deterioration  of  the  general  health  of  those 
addicted  to  the  immoderate  use  of  alcohol  should  be  remedied  by  a  proper 
regulation  of  their  habits. 

In  cases  of  very  extensive  loss  of  integument,  skin-grafting  will  give  very 
gratifying  results.  If  this  should  fail,  circumcision  of  the  callous  ulcer  by 
a  deep  cut  carried  through  the  fascia,  according  to  Nussbaum,  may  be  tried. 
The  incision  should  be  placed  about  one  third  of  an  inch  from  the  edge  of 
the  sore. 

(c)  Acute  Suppuratiox  of  the  Peepatellary  Bursa. — Servant-girls 
and  scrub-women,  in  short,  persons  frequently  subject  to  house-maid's 
knee  or  simple  synovitis  of  the  prepatellary  bursa,  are  frequently  victims  to 
phlegmonous  inflammation  of  the  same  organ.  The  symptoms  are  those  of 
a  subcutaneous  phlegmon,  heightened  by  the  circumstance  that,  the  phleg- 
monous focus  being  encapsulated,  great  tension  is  apt  to  develop.  Extensive 
necrosis  and  serious  septic  intoxication  must  result  if  no  timely  relief  is 
afforded. 

Dense,  hard  infiltration  and  a  deep-red  flush  of  the  prepatellary  region, 
with  oedema,  high  fever,  and  marked  sickness,  are  present.  The  general 
intumescence  may  cause  errors  in  diagnosis,  as  inexperienced  observers  are 
apt  to  look  for  the  source  of  the  trouble  within  the  knee-joint.  This  mis- 
take can  be  avoided  by  noting  that  in  septic  bursitis  the  point  of  the  most 
intense  swelling,  redness,  and  pressure-pain  is  over  the  patella,  whereas  in 
gonitis  pressure  over  the  juncture  of  the  femur  and  tibia  laterally  of  the 
patella  is  most  painful,  and  the  patella  can  be  distinctly  felt  floating  on  top 
of  the  exudation  within  the  knee.  A  free  incision  into  the  bursa,  together 
with  Volkmann's  multiple  puncture  of  the  inflamed  skin,  is  the  proper 
treatment.  The  cavity  should  be  well  irrigated  with  corrosive-sublimate 
lotion,  loosely  packed  with  strips  of  iodoformed  gauze,  and  inclosed  in  a 
7noist  dressing,  which  should  be  daily  changed. 

(d)  Acute  Suppuration  of  the  Kxee-joint  is  one  of  the  most  formi- 
dable types  of  phlegmon.  On  its  prompt  recognition  and  energetic  treat- 
ment may  depend  the  safety  of  limb  and  life.  It  should  be  well  distin- 
guished from  the  more  bland,  so  called,  "  catarrhal'"  (Volkmann)  inflamma- 
tions of  the  synovial  membrane,  due  to  tuberculosis  or  to  rheumatic  and 
gonorrhoeal  influences  ;  and  also  from  metastatic  suppuration  complicating 
pyaemia. 

It  is  generally  caused  by  infection  of  the  joint  from  without  through 
accidental  or  surgical  wounds,  or  by  its  invasion  of  a  suppurative  process 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  257 

established  in  the  vicinity,  as,  for  instance,  acute  osteomyelitis  or  a  subcu- 
taneous or  bursal  phlegmon.  Idiopathic  acute  suppuration  of  the  knee- 
joint  is  very  rare  indeed. 

The  invasion  is  marked  by  one  or  more  sharp  chills,  very  high  fever, 
and  a  sudden  painful  intumescence  of  the  Joint.  The  limb  is  rotated  out- 
ward, lying  on  its  outer  aspect,  is  flexed  at  an  obtuse  angle,  and  its  2Dosition 
is  carefully  maintained  by  the  patient,  as  the  constant  pain  is  terribly  in- 
tensified by  the  least  change  of  posture.  General  oedema  and  reddening  of 
the  integument  soon  follow,  the  septic  intoxication  frequently  j^i'oducing 
delirium  and  a  typhoid  condition. 

The  intra-articular  tension  increasing,  perforation  of  the  capsule,  gener- 
ally upward  through  the  bursal  extension  of  the  joint  beneath  the  quadri- 
ceps tendon,  occurs,  and  is  marked  by  a  temporary  remission,  of  the  in- 
tensity of  the  local  and  sometimes  of  the  general  symptoms.  One  or  more 
subfascial  or  subcutaneous  abscesses,  located  on  one  or  both  sides  of  the 
quadriceps,  appear,  and  rapidly  extend  upward  and  outward  until  perfora- 
tion of  the  skin  permits  the  escape  of  the  enormous  mass  of  pent-up  pus. 
Occasionally  the  matter  joerforates  backward  into  the  popliteal  space,  this 
way  being  marked  out  by  the  bursse  situated  beneath  the  popliteus  muscle, 
which  are  frequently  in  open  communication  with  the  knee-joint.  In  this 
case  the  abscess  will  extend  downward  along  and  beneath  the  muscles  of  the 
calf. 

Spontaneous  perforation  will  not  bring  about  complete  and  lasting  relief, 
as  the  drainage  is  and  must  be  inadequate.  Profuse  suppuration  and  a  con- 
suming fever,  with  frequent  chills  and  colliquative  sweats,  will  in  a  short 
time  so  depress  the  patient's  condition,  that  amputation  will  have  to  be 
thought  of  as  the  last  resort  for  saving  life. 

The  treatment  should  be  that  of  deep-seated  phlegmon,  modified  by  the 
requirements  of  the  anatomical  peculiarities  of  the  knee-joint.  The  cavity 
of  the  knee-joint  naturally  consists  of  three  distinct  recesses :  one  below,  the 
other  above  the  patella ;  the  third  is  an  extension  of  the  suprapatellar  space, 
and  is  known  by  the  name  of  the  bursa  of  the  quadriceps.  In  flexion, 
where  the  knee-pan  is  firmly  held  down  to  the  condyles,  the  infra-  and 
supra-patellar  spaces  become  practically  non-communicating.  Andrews  of 
Chicago,  to  whom  we  owe  a  most  excellent  treatise  on  the  subject  of  injuries 
to  the  joints,  mentions  a  case  *  of  traumatic  suppuration  of  the  infra- 
patellar recess  of  the  knee-joint,  where,  by  means  of  continued  flexion  and 
thorough  disinfection  and  drainage  of  the  same  space,  general  infection  of 
the  joint  was  eifectually  prevented. 

To  effect  adequate  drainage  of  a  phlegmonous  knee-joint,  each  of  these 
recesses  must  be  separately  incised  and  drained. 

A  double  incision  of  each  of  these  spaces  will  be  much  more  effective 
than  a  single  one,  as  it  will  permit  more  thorough  irrigation.  In  very 
infectious  cases  two  additional  incisions  will  drain  away  pus  retained  in  the 
reflection  of  the  capsule  from  the  vicinity  of  the  crucial  ligaments. 

*  Ashhurst's  "  Encyclopedia  of  Surgery,"  vol.  iii,  p.  723. 


258  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

The  first  incision  should  be  made  in  the  suprapatellar  space  on  the 
inner  side,  where  the  capsule  is  the  most  ample.  Haemorrhage  is  generally 
profuse,  hence  it  is  best  to  penetrate  the  tissues  gradually,  and  to  secure 
each  bleeding  vessel  as  soon  as  it  is  cut.  As  soon  as  the  joint  is  entered,  a 
dressing  forceps  is  thrust  through  it  to  the  corresponding  point  of  the  other 
side  of  the  joint,  where  the  second  incision  is  to  be  made  through  the  tissues 
raised  by  the  pressure  of  the  forceps.  The  point  of  the  forceps  emerging 
from  this  incision,  a  stout  drainage-tube  is  grasped  with  it,  and  drawn  into 
the  Joint  just  far  enough  to  clear  the  synovial  membrane.  A  similar  piece 
of  drainage-tubing  is  inserted  into  the  first  incision,  and  the  protruding 
ends  of  the  tubes,  being  transfixed  with  safety-pins,  are  cut  off  on  a  level 
with  the  skin.  The  infrapatellar  and  submuscular  spaces  are  treated 
similarly,  and,  if  necessary,  the  lateral  poaches  of  the  joint  are  also  in- 
cised and  drained.  The  cavities  are  thoroughly  flushed  out  with  corrosive- 
sublimate  lotion,  a  large  moist  dressing  is  fastened  on,  and  the  limb  is 
secured  to  a  posterior  splint  to  insure  rest  and  painlessness  during  unavoid- 
able changes  of  posture  of  the  patient.  Wherever  perforation  of  the  capsule 
and  formation  of  a  circumarticular  abscess  has  occurred,  this  must  be  sepa- 
rately incised  and  drained. 

In  the  great  majority  of  cases,  resolute  and  comprehensive  measures  of 
this  kind  will  be  rewarded  by  prompt  improvement.  Daily  change  of  dress- 
ings and  irrigation  should  be  practiced  until  the  disappearance  of  all  the 
inflammatory  and  febrile  symptoms.  As  soon  as  the  discharges  become 
scanty  and  serous,  the  drainage-tubes  can  be  withdrawn  one  by  one.  Where 
the  affection  is  due  to  osteomyelitis,  anchylosis  will  result  as  a  rule,  espe- 
cially in  grown  individuals.  In  children,  prompt  and  adequate  drainage 
frequently  results  in  preservation  of  mobility. 

Case  I. — Charles  Hundertmark,  aged  four.  Acute  suppuration  of  knee-joint  caused 
by  a  blow  upon  head  of  tibia.  May  31,  1875. — Three  incisions — one  on  each  side  into 
the  suprapatellar  space,  a  third  one  into  the  quadriceps  bursa.  Daily  change  of  moist 
carbolized  dressings  and  irrigation.  Rapid  improvement.  June  l5th. — Drainage  aban- 
doned.    July  Jfth. — Perfect  recovery  noted,  with  free  active  use  of  the  joint. 

Case  II. — John  S.,  grocer,  aged  nineteen.  Acute  suppuration  of  knee-joint,  with 
terrible  pain  and  typhoid  symptoms.  The  patient  was  brought  to  the  German  Hos- 
pital .January  10,  1880,  by  Dr.  Schwedler,  who  administered  chloroform  during  the 
transfer,  to  allay  the  patient's  suffering  from  the  jolts  of  the  carriage.  Immediate  typi- 
cal multiple  incisions  and  drainage.  The  index-finger  detected  a  roughened  place  on 
the  articular  surface  of  the  inner  condyle  of  the  femur.  Undoubtedly  on  account  of 
the  osteomyelitic  process,  the  febrile  symptoms  receded  very  slowly.  Permanent  irri- 
gation of  the  joint  rendered  the  frequent,  terribly  painful  change  of  the  dressings 
unnecessary.  A  few  small  sequestra  belonging  to  the  cancellous  tissue  of  the  femoral 
epiphysis  came  away  on  the  twenty-tliird  day.  Patient  was  discharged  cured,  March 
20th,  with  firm  anchylosis. 

In  exceptionally  neglected  cases,  where  the  process  has  assumed  the 
character  of  a  general  purulent  infiltration,  incisions  and  drainage,  supple- 
mented with  continuous  irrigation,  will  not  be  followed  by  as  prompt  im- 
provement as  is  desirable.     The  continued  high  fever,   the  formation  of 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  259 

new  abscesses,  will  certainly  bring  about  a  fatal  termination,  unless  the 
limb  is  amputated  clearly  beyond  the  limits  of  the  disease.  So-called  con- 
seryatiye  measures — as,  for  instance,  exsection  of  the  joint — are  entirely 
inadmissible  and  dangerous  under  these  circumstances.  They  will  fail  to 
remove  from  the  affected  parts  the  elements  of  contamination,  as  the  most 
rigid  antiseptic  measures  of  the  ordinary  kind  are  here  utterly  inadequate. 
The  phlegmonous  process  will  attack  the  newly-made  wound-surfaces,  and 
the  patient's  life  will  be  placed  in  the  greatest  jeopardy  by  secondary  hasmor- 
rhage.     The  following  case  forcibly  illustrates  the  weight  of  these  remarks : 

Case. — Max  LofFmann,  butcher,  aged  twenty.  Admitted,  October  25,  1885,  to 
Mount  Sinai  Hospital.  October  12th. — The  submuscular  recess  of  the  knee-joint  was 
accidentally  incised  with  a  filthy  butcher's  knife.  Some  synovia  escaped  from  the 
small  puncture ;  after  the  accident  the  patient  walked  home.  Suppuration  of  the  knee- 
joint  set  in  the  following  day,  with  rigors  and  general  dejection.  The  wound  was 
dressed  by  a  Jersey  City  practitioner  with  an  adhesive-plaster  dressing  placed  over  the 
incision.  The  patient  was  admitted  to  the  hospital  in  a  highly  septic  condition,  large 
quantities  of  thin,  ichorous  pus  escaping  from  the  joint  on  shght  pressure.  Immedi- 
ately the  patient  was  anaesthetized,  and  typical  incision  and  drainage  were  done.  The 
synovial  lining  of  the  joint  was  coated  with  a  greenish-gray  adherent  and  putrid  mem- 
brane, in  looks  identical  with  the  membranous  coating  in  pharyngeal  diphtheria.  A 
number  of  small,  purulent  foci  were  opened  by  the  incisions  made  for  drainage  of  the 
joint. '  A  moist  dressing  and  dorsal  splint  were  applied.  In  spite  of  frequent  irriga- 
tion, no  remission  of  the  high  fever  or  local  pain  following,  amputation  of  the  thigh 
was  proposed,  in  view  of  the  visible  failing  of  the  patient's  strength.  This,  however, 
was  resolutely  declined  by  the  patient  and  his  widowed  mother,  who  begged  for  an 
attempt  to  save  the  limb.  The  author,  against  his  better  judgment,  performed  exsec- 
tion of  the  knee-joint,  November  6th.  Esmarch's  band  was  applied  to  the  upper  third 
of  the  thigh  without  the  previous  use  of  the  elastic  roller  bandage,  and  a  continuous 
stream  of  corrosive-sublimate  lotion  (1  :  1,000)  was  kept  playing  upon  the  wound  during 
the  entire  opei-ation,  which  was  rapidly  but  carefully  performed.  Care  was  taken  to 
operate  in  healthy  parts,  and  all  the  involved  tissues  w-ere  removed.  The  wound 
was  drained  and  closed  in  the  usual  manner,  and  the  dressed  limb  was  fixed  upon 
a  dorsal  splint.  Suppuration  of  the  wound  followed,  requiring  frequent  changes 
of  dressing  and  irrigation,  the  secretions  retaining  all  the  while  their  peculiar  thin, 
ichorous  character  noted  from  the  outset.  On  the  afternoon  of  November  18th,  pro- 
fuse arterial  hsemorrhage  occurred  from  the  wound,  which  was  temporarily  checked 
by  the  house-surgeon  with  the  application  of  Esmarch's  baud.  Being  hastily  sum- 
moned to  the  hospital,  the  author  found  the  patient  blanched  and  collapsed.  About 
twenty  ounces  of  a  6  :  1,000  watery  solution  of  cooking  salt  were  transfused  into  his 
median  vein,  and  resulted  in  a  notable  improvement  of  the  pulse.  Amputation  of  the 
thigh  was  quickly  done  as  a  last  resort.  The  patient,  however,  expired  before  the 
removal  of  Esmarch's  band. 

Post-mortem  examination  revealed  a  sieve-like  perforation  of  the  popliteal  vein 
and  a  large  oblong  defect  of  the  popliteal  artery,  both  of  which  were  found  exposed 
and  surrounded  by  a  massive  blood-clot.  The  walls  of  the  cavity  containing  the  clot 
consisted  of  broken-down  and  necrosed  tissues. 

There  is  little  doubt  that  an  early  amputation  might  have  saved  the  patient's  life. 

(e)  StfPPUEATiOF  OF  THE  Ingtjikal  Glan'ds. — Two  groups  of  lym- 
phatic glands  have  to  be  distinguished  in  the  inguinal  region — one  situated 

35 


2(J0  RULES   OF  ASEPTIC  AND  ANTISEPTIC   SURGERY. 

below  Poii})art's  ligament,  tiie  other  above  it.  The  subingiiinal  group  is 
frequently  the  seat  of  phlegmonous  inflammation,  due  to  absorption  of  sep- 
tic material  from  sores  caused  by  the  pressure  of  ill-fitting  shoes,  ulcerated 
bunions,  ingrowing  toe-nail,  and  excoriations  of  the  lower  extremity  from 
scratching  in  eczema.  Their  treatment  by  incision  does  not  require  special 
elucidation. 

Should,  however,  their  excision  become  necessary,  the  rules  laid  down 
for  the  removal  of  tumors  from  Scarpa's  triangle  (pages  52  and  55)  should 
be  heeded. 

Acute  suppuration  of  the  sui)rainguincd  glands  is  caused  most  generally 
by  ulcerative  or  suppurating  processes  of  the  generative  organs.  Their 
treatment  is  subject  to  the  principles  accepted  for  glandular  abscesses  of  other 
regions,  and  may  be  dismissed  with  the  remark  that  the  hest  loay  to  incise 
them  is  not  parallel,  hut  at  a  right  angle  with  the  direction  of  the  fihers  of 
FotijMrfs  ligament.  The  edges  of  the  incision  will  gap  asunder,  and  afford 
very  good  drainage  even  without  the  use  of  a  tube,  and,  later  on,  the  edges 
of  the  cut  will  not  exhibit  the  tendency  to  become  inverted,  which  is  the 
source  of  much  trouble  in  the  after-treatment. 

Interminable  chronic  suppuration  of  the  suprainguinal  glands  fre- 
quently indicates  their  bodily  extirpation.  The  safest  way  of  accomplishing 
their  removal  is  as  follows  :  Two  semi-elliptic  incisions  should  include  all 
the  fistulous  openings  leading  into  the  glandular  swelling.  They  should 
be  gradually  deepened  until  a  comparatively  healthy  part  of  the  swelling  is 
exposed.  Here  the  capsule  is  incised,  and  the  mass  is  carefully  dissected 
out  with  the  tip  of  a  pointed  scalpel.  Blunt  dissection  should  be  resorted 
to  only  where  it  is  evidently  easy,  as  in  using  much  blunt  force  the  glands 
may  be  ruptured,  and  their  contents  soil  the  wound. 

This  injunction  is  important,  as  intentioncd  or  unintentional  injury 
to  the  peritonoium  may  become  unavoidaMe.  Should  the  epigastric  vessels 
be  in  the  way,  they  must  be  cut  and  deligated.  Attention  ought  to  be  paid 
also  to  the  seminal  cord,  which  occasionally  enters  into  very  close  relations 
with  inguinal  glandular  swellings. 

/".  Perityphlitic  Abscess  : 

Up  to  within  a  recent  period  of  time  it  was  the  prevalent  belief  that  peri- 
typhlitic suppuration  was  located  retroperitoneally,  and  most  generally  in 
the  iliac  fossa,  whence  it  found  its  way  to  the  surface  by  pushing  aside  the 
peritoneal  reflection  corresjDonding  to  Poupart's  ligament.  Willard  Par- 
ker's method  of  incising  perityphlitic  abscess  was  based  upon  this  view. 

It  Ctin  not  be  denied  that  the  development  of  most  circuniappendicular 
abscesses  seems  to  confirm  tliis  view,  and  that  the  rules  laid  down  by  Par- 
ker for  the  treatment  of  this  grouj)  of  suppurative  processes  have  yielded, 
and  continue  to  yield,  very  satisfactory  results  in  very  many  instances. 
Still,  it  must  be  said  that  the  exceptions  to  Parker's  type  are  considerable  in 
number.  Formerly  they  were  classed  as  cases  of  general  or  localized  "idio- 
pathic peritonitis."  Their  treatment  was  non-surgical,  and  their  issue  very 
uncertain  and  often  fatal. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  261 

Vv"e  owe  the  better  understanding  of  the  elements  of  this  phenomenon 
to  Treves  and  Weir,  but  principally  to  McBurney,  who  demonstrated  that 
in  the  vast  majority  of  instances  the  formation  of  abscess  in  the  right  iliac 
fossa  was  due  to  intraperitoneal  inflammatory  processes,  mostly  of  the  ver- 
miform appendix,  and  commonly  accompanied  by  ulceration,  necrosis,  and 
perforation  of  this  viscus.  The  frequency  of  the  location  of  perityphlitic 
abscess  near  the  parietes  of  the  right  iliac  fossa  is  explained  by  the  fre- 
quency of  the  sujDerficial  sifiis  of  the  appendix  in  this  region.  In  these 
cases  the  type  of  development  so  well  described  by  Parker  will  prevail.  But 
in  a  very  large  proportion  of  instances  the  vermiform  appendix,  either  con- 
genitally  or  in  consequence  of  acquired  peculiarity,  occupies  a  deep  situa- 
tion, and  in  these  cases  an  aj^pendicular  perforative  process  is  sure  to  cause 
a  deep-seated  intraperitoneal  abscess,  more  or  less  distant  from  the  surface, 
hence  infinitely  more  grave  and  dangerous  both  as  regards  its  deleterious 
possibilities  and  the  difficulty  of  diagnosis  and  surgical  management.  As 
soon  as  it  became  clear  that  widely  different  intraperitoneal  forms  of  suppu- 
ration might  be  caused  by  extension  from  the  appendix,  and  that  their  man- 
ner of  development  was  wholly  unforeseen  and  unaccountable,  a  violent 
oscillation  in  therapy  w^'as  initiated  by  those  who  proposed,  in  all  cases  where 
the  appendix  was  suspected  of  causing  trouble,  a  bold  exploration  by  abdom- 
inal section,  and  the  extirpation  of  the  appendix,  or  evacuation  at  all  haz- 
ards of  the  purulent  collection,  wherever  it  might  be  found,  and  all  this 
without  delay. 

Though  this  bold  course  of  therapy  has,  in  spite  of  its  experimental 
character,  yielded  very  good  results  in  the  hands  of  various  surgeons,  and 
although  its  adoption  was  absolutely  necessary  for  establishing  a  clearer 
understanding  of  the  nature  of  the  morbid  process  in  question,  neverthe- 
less it  must  be  remembered  that  a  vast  proportion  of  perityphlitic  abscesses 
do  not  need  operative  invasion  of  the  free  peritoneal  cavity  for  their  success- 
ful care,  and  that  a  sweeping  advice  to  the  general  profession  to  open  the 
peritonaeum  in  every  case  where  appendicular  trouble  is  suspected  is,  for  ob- 
vious reasons,  fraught  with  much  unwarrantable  danger. 

Formerly  it  was  considered  purely  accidental  whether  an  intraperitoneal 
abscess  would  appear  here  or  there,  and  the  variability  of  the  surroundings 
and  location  of  these  abscesses  was  deemed  so  irregular  and  erratic  that,  to 
the  author's  knowledge,  no  attempt  was  ever  made  to  study  the  question 
whether  a  certain  order  of  development  did  not  prevail  even  in  those  forms 
of  perityphlitic  abscess  which  could  not  be  classed  with  the  well-known 
inguinal  type  described  by  Parker.  If  some  light  could  be  thrown  upon 
the  detailed  nature  of  these  seemingly  erratic  forms  of  circumappendicular 
abscess,  instead  of  the  crude  general  advice  to  •'•perform  laparotomy,*'  more 
precise,  hence  safer,  methods  of  treatment  would  suggest  themselves. 

Let  us  first  emphasize  the  fact  that  all  intraperitoneal  abscesses  are  of 
visceral  origin,  and  that  perityphlitic  abscess  in  particular  is  due  to  inflam- 
matory processes  located  in  the  vermiform  appendix.  Though  not  always, 
this  form  of  abscess  is  mostly  established  within  the  peritoneal  sac. 


262  RULES  OF  ASEPTIC  AND  ANTISEPTIC   SURGERY. 

The  proof  of  this  assertion  has  been  so  manifolil  that  it  is  only  necessary  to  refer  to 
the  niuueroiis  cases  of  early  a])pendicitis  reported  by  McBurney  and  other  observers, 
in  which,  on  laparotomy,  the  free  appendix  was  found  to  be  tightly  distended  by  a 
copious  exudate,  and  more  or  less  erect  by  dint  of  its  extreme  distention;  its  walls 
thickened,  hypersemic,  occasionally  exhibiting  unmistakable  signs  of  circumscribed 
necrosis  with  perforation  imminent.  This  distention  was  uniformly  produced  by  occlu- 
sion toward  the  gut.  Occasionally  decay  had  j)rogressed  to  actual  perforation  and  the 
formation  of  incipient  abscess,  surrounded  by  a  protective  barrier  of  recent  adhesions  of 
the  vicinal  serous  surfaces.  The  appendix  was  invariably  found  to  be  the  starting-point 
of  the  trouble,  and  the  affection,  with  rare  exceptions,  always  intraperitoneal.  Asiile 
from  the  numerous  instances  in  which  the  intraperitoneal  and  appendicular  character 
of  perityphlitis  was  established  by  positive  observation,  the  following  case  may  serve 
to  show  that  the  retroperitoneal  space  back  of  the  iliac  fossa  is  not  the  seat  of  abscess 
in  typical  cases  of  perityjihlitis.  In  the  spring  of  1887  I>r.  Lellmann,  then  on  duty  in 
the  German  Hospital,  requested  the  autlior  to  operate  on  a  case  of  perityphlitis  pertain- 
ing to  his  service.  The  operation  was  delayed  twenty-four  hours  on  account  of  a  mis- 
understanding, and  the  next  day — a  dense,  painful  tumor  being  found  in  the  right  iliac 
region — incision  according  to  Parker  was  done,  in  spite  of  the  circumstance  that  the 
size  of  the  swelling  had  somewhat  diminished  since  the  previous  day.  The  peritoneal 
lining  of  the  iliac  fossa  was  easily  stripped  up  two  inches  beyond  the  external  iliac  ves- 
sels, so  that  the  tuuaor  was  freely  raised  with  it  from  the  underlying  tissues.  No  sign 
of  inflammation  was  found,  and,  as  the  case  was  mending,  it  was  not  deemed  prudent 
to  incise  the  peiitonfeum.  The  very  deep  wound  was  drained  and  closed,  but  no  pus 
appeared.  Simultaneously  with  the  healing  of  the  incision  the  tumor  disappeared,  and 
the  man  was  discharged  cured  within  a  fortnight  after  the  operation. 

We  need  not  do  more  than  hint  at  the  causes  of  appendicular  inflamma- 
tion. Let  us  first  mention  the  impaction  of  foreign  bodies  entering  from 
the  gut,  acute  or  chronic  forms  of  catarrhal  or  ulcerative  (typhoid)  enteri- 
tis, transmitted  from  the  colon  and  leading  to  simple  hypertrophy  or  to 
ulceration,  both  of  these  causing  irregular  constriction  mostly  in  the  vicin- 
ity of  the  attachment  of  the  appendix.  Another  not  infrequent  cause  of 
stenosis  is  the  doubling  upon  itself  and  fixation  of  the  appendix  in  this  posi- 
tion. Stenosis  by  flexion  is  thus  produced.*  With  the  establishment  of 
hypertrophy  and  stenosis  a  loss  of  contractile  power  is  associated,  leading 
to  more  or  less  complete  retention  and  to  the  inspissation  of  fecal  matter, 
which  finally  assumes  the  shape  of  one  or  more  globular  concrements.  As 
long  as  the  communication  with  the  colon  is  fairly  open,  no  local  symptoms 
need  prevail.  As  soon  as  the  stenosis  becomes  considerable,  the  well-known 
signs  of  appendicitis  make  their  appearance.  If  they  are  due  to  a  passing 
state  of  catarrhal  hyperaemia,  their  acuteness  will  vary  in  proportion  with 
the  intensity  of  the  stenosis.  Thus,  with  the  cessation  of  causal  intumescence 
and  the  elimination  of  the  stenosis  maintained  by  it,  all  trouble  may  seem- 
ingly or  really  disappear.  A  case  reported  by  Shrady  f  aptly  illustrates  this 
train  of  symptoms 

*  F.  W.  Murray,  "  New  York  Medical  Journal,"  May  24,  1890,  p.  564. 

■f  George  F.  Shrady,  Meeting  of  Practitiouers'  Society  of  New  York.  "  Medical  Record," 
April  lie,  1890,  p.  479. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  263 

A  physician  had  had  four  distinct  attacks  of  appendicitis,  in  all  of  which  the  ques- 
tion of  operation  arose.  Dr.  Shrady  had  seen  the  patient  at  New  York  in  three  of  the 
attacks,  all  of  which  were  well  pronounced,  while  the  fourth  occurred  in  Paris,  where 
the  patient  was  seen  by  a  distinguished  surgeon,  who  made  a  like  diagnosis.  There 
also  the  question  of  an  operation  came  up.  Each  attack  was  attended  with  all  the 
usual  severe  symptoms  which  would  appear  to  usher  in  the  formation  of  an  abscess; 
there  were  dullness,  tenderness,  more  or  less  rigidity,  and  some  oedema  in  the  neighbor- 
hood of  the  caecum.  In  each  attack  the  advisability  of  operation  was  freely  discussed. 
The  patient  was  willing  to  take  the  risks,  but  in  each  instance  the  symptoms  gradually 
disappeared,  and  he  recovered.  He  asked  Dr.  Shrady,  should  he  survive  him,  to  ex- 
amine his  appendix,  which  was  done  when  death  occurred,  some  time  subsequently,  of 
another  cause.  The  appendix  teas  found  perfectly  sound.  There  was  not  the  slightest 
appearance  of  any  inflammation  around  it ;  it  was  not  even  thickened. 

"Where  ulcerative  processes  have  led  to  the  formation  of  a  permanent 
cicatricial  contraction,  the  appendical  trouble  is  apt  to  persist  even  after 
the  cessation  of  the  causal  disorder  of  the  intestine.  Passing  states  of  local 
intumescence  are  then  more  likely  to  lead  to  complete  occlusion  of  the  com- 
munication between  gut  and  appendix,  with  serious  consequences.  But 
even  in  these  cases  temporary  improvements  are  possible  with  the  diminu- 
tion of  the  acute  swelling  of  the  cicatricial  mass. 

Before  attempting  a  practical  classification  of  the  phases  of  appendicitis 
and  of  the  localities  in  which  circumappendicular  suppuration  is  to  be  ob- 
served, this  fact  has  to  be  pointed  out :  that,  unfortunately,  the  acuteness 
or  mildness  of  the  local  or  general  symptoms  is  not  an  invariable  index  of 
the  ultimate  gravity  of  a  given  case.  Sometimes  fatal  cases  will  set  in  with 
a  very  deceptive  mildness  of  appearances.  On  the  other  hand,  a  very  alarm- 
ing beginning  may  be  followed  by  resolution  or  a  tractable  state  of  affairs. 
Hence  it  must  be  insisted  on  that,  in  reference  to  this  trouble,  all  thera- 
peutic advice  has  only  a  conditional  value — to  be  weighed  and  accepted  or 
rejected  by  the  surgeon  in  each  separate  case. 

a.  Acute  Appei^dicitis  (without  Tumor). — {a)  Simple  Appendicitis 
{no  Tumor). — Anatomy  teaches  that  in  the  supine  body  the  attachment  of 
the  vermiform  appendix  can  be  found  directly  underneath  a  point  located 
two  inches  from  the  anterior  superior  spine  of  the  ilium,  on  a  line  connecting 
this  bony  prominence  with  the  navel.  Whenever  acute  and  persistent  pain 
appears  in  this  region,  accompanied  by  fever  and  retching,  the  pain  being 
markedly  increased  by  palpation  of  this  area,  trouble  of  the  appendix  can 
be  confidently  diagnosticated.  In  women,  bimanual  palpation  ought  to  ex- 
clude the  joresence  of  an  inflammatory  process  of  the  displaced  uterine  ap- 
pendages. Though  the  local  and  general  symptoms  may  be  very  alarming, 
tumor  can  rarely,  if  ever,  be  detected  in  the  early  stages  of  the  affection. 
Meteorism  is  also  absent. 

In  view  of  the  impossibility  of  foretelling  whether,  in  a  given  case, 
spontaneous  evacuation  of  the  contents  of  the  appendix  or  perforation  is 
to  take  place,  and  in  the  latter  case  whether  a  superficial  or  a  deep-seated 
abscess  is  to  develop  ;  and,  considering  the  fact  that  laparotomy  followed 
by  excision  of  the  appendix  has  yielded  uniformly  good  results  if  done  be- 


264  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


Fig.  183. — Incising  peritypbilitic  abscess. 


fore  the  access  of  perforation,  it  is  safe  to  follow  McBurney's  advice,  which 
recommends  laparotomy  and  removal  of  the  appendix  whenever  severe 
.symptoms  persist  and  increase  for  more  than  forty-eight  hours. 

The  steps  of  the  operation  are  these  :  A  longitudinal  incision,  four  or 

five  inches  long,  parallel  with  and 
just  outside  of  the  outer  margin  of 
the  right  rectus  muscle.  Having 
opened  the  peritonaeum,  the  appen- 
dix is  found,  which  will  be  rendered 
easy  by  first  ascertaining  the  location 
of  the  caput  coli.  The  mesentery  of 
the  appendix  is  included  in  a  double 
ligature  of  stout  catgut  and  divided. 
Then  the  root  of  the  appendix  is 
secured  by  two  ligatures,  between 
which  the  viscus  is  cut  off.  The 
mucous  lining  of  the  stump  is  either 
seared  with  tl.e  thermo-cautery,  or,  after  careful  disinfection,  is  touched 
with  a  few  drops  of  iierchloride-of-iron  solution  and  dried  off.  Then  the 
stump  is  dropped  back  and  the  external  wound  is  closed. 

Case.— Miss  F.  L.,  aged  tsveiity.  Has  had  altogether  sixteen  or  eighteen  attacks 
of  appendicitis  within  two  years.  Characteristic  local  pain,  irregular  fever  with  tem- 
peratures reafhing  104°  Fahr. ;  no  tumor.  Uterine  appendages  normal.  April  20, 
1890. — Laparotomy.  The  free  appendix  is  found  very  nmch  thickened,  its  distal  half 
distended  and  bent  upon  itself,  containing  a  quantity  of  fetid  serum.  It  was  removed. 
Uninterrupted  recovery. 

{b)  Perforative  Appendicitis  {no  Tumor). — Sudden  increment  and  ex- 
tension of  the  local  pain  followed  by  symptoms  of  collapse,  such  as  profuse 
cold  sweating,  a  thready  pulse,  anxious  expression,  pallor,  frequent  vomit- 
ing, and  the  appearance  of  meteorism  are  indications  that  perforation  and 
infection  of  the  peritona?um  have  taken  place.  This  rarely  occurs  before 
two  or  three  days  after  the  ince])tion  of  the  trouble.  The  violence  of  the 
symptoms  will  depend  on  these  factors.  If  the  extent  of  the  perforation  is 
small,  and  only  a  small  quantity  of  the  infectious  contents  of  the  appendix 
has  made  its  way  into  the  peritonaeum,  a  limiting  barrier  of  protective  ad- 
hesions may  be  thrown  about  the  infected  area  within  an  hour  or  so.  In 
this  case  the  alarming  features  of  the  case  will  somewhat  subside  and  a 
tumor  is  ai)t  to  develop.  If,  on  the  other  hand,  the  perforation  is  large  or 
multiple,  a  considerable  volume  of  infectious  material  will  suddenly  escape. 
Lively  peristaltic  action  will  widely  distribute  it,  and  more  or  less  extensive 
local  or,  in  the  worst  cases,  general  septic  peritonitis  will  be  established. 

The  absence  of  tumor  in  conjunction  with  very  acute  local  and  general 
symptoms  represents  an  extremely  grave  combination  of  things,  its  meaning 
being  a  generalizing  peritonitis.  In  these  cases  the  prognosis  is  very  doubt- 
ful, and  it  will  be  extremely  difficult  to  save  the  patient,  even  by  the  most 
resolute  measures.     If  laparotomy  is  immediately  done,  the  focus  laid  open. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  285 

wiped  out  clean,  the  appendix  removed,  and  the  cavity  packed  and  drained, 
some  chances  may  still  be  present  for  the  patient's  recovery.  But  where, 
on  account  of  delay,  numerous  and  widely  disseminated  abscesses  have 
established  themselves  in  the  more  remote  parts  of  the  peritoneal  cavity,  the 
patient's  death  is  nearly  certain.  Prolonged  exposure,  the  impossibility  of 
a  sufficient  evacuation  and  drainage  of  the  foci  which  are  found,  finally 
the  overlooking  of  distant  foci  located  in  the  loins,  in  front  and  behind  the 
liver,  will  sufficiently  explain  this  fact. 

Cass  I. — William  Sachse,  aged  fortv-eight,  liquor-dealer.  Was  treated  since 
September,  1889,  in  the  internal  department  of  the  German  Hospital  for  alcoholic 
neuritis.  No  habitual  constipation.  March  23,  1890. — Sudden  chill.  Temperature, 
105°  Fahr.  Slight  amygdalitis.  No  abdominal  symptoms.  The  temperature  remained 
high,  although  the  patient's  bowels  were  well  purged  with  calomel  on  March  25th. 
Had  a  chill  in  the  preceding  night,  another  one  in  the  afternoon,  complaining  the  first 
time  of  belly-aclie.  ^7^A.— Pain  well  marked  in  ileo-ca^cal  region.  Was  transferred  to 
surgical  service.  Temperature,  104-4°  Fahr.  Meteorism,  intense  pain  in  the  ileo-cgecal 
region,  but  no  tumor  and  no  dullness.  Vomited  only  once.  Laparotomy  at  3  p.  m. 
McBurney's  incision.  Peritoneum  filled  with  turbid  serum.  Omentum  widely  adher- 
ent to  caecum,  in  front  of  which  an  adherent  and  very  much  thickened  and  elongated 
vermiform  appendix  was  found.  On  freeing  this,  a  large,  irregular  abscess  cavity  was 
opened,  which  did  not  anywhere  approach  the  parietes,  and  which  was  situated  below 
and  behind  the  cfecum,  its  walls  being  formed  everywhere  by  intestines.  At  the  root 
of  the  appendix  a  large  perforation  was  seen,  with  three  globular  fecal  concrements 
lying  in  front  of  and  outside  of  it.  The  appendix  contained  three  more  globular  con- 
crements of  the  size  of  a  small  marble.  The  appendix  was  isolated,  tied,  and  cut 
off.  Another  large  abscess  situated  in  the  median  line,  and  a  third  one  in  Doug- 
las's pouch,  were  opened,  irrigated,  and  drained.  Hasty  partial  closure  of  incision 
after  packing  and  drainage  of  the  abscesses  on  account  of  collapse.  In  the  night 
the  temperature  rose  to  106°  Fahr.,  and  the  patient  expired  toward  midnight.  Post- 
mortem examination  revealed  three  more  abscesses,  one  situated  high  up  behind 
the  liver. 

Case  II. — David  Danziger,  tailor,  nged  twenty-two.  General  peritonitis  due  to 
perforative  appendical  trouble  of  six  days'  duration.  Laparotomy  January  29,  1889, 
at  Mount  Sinai  Hospital.  Seven  abscesses  were  opened  and  drained.  Patient  seem- 
ingly improved,  the  quality  of  the  pulss  improving.  Vomiting  ceased,  but  he  collapsed 
suddenly  thirty  hours  after  the  operation  and  died.  Post-mortem  examination  re- 
vealed three  perihepatic  abscesses. 

i.  Acute  Appbistdicitis  with  Tumor  ;  Perityphlitic  Abscess. — 
AVhenever  perforation  of  the  free  appendix  occurs,  the  invasion  of  the 
peritonaeum  is  regularly  signalized  by  the  usual  symptoms  of  perforative 
peritonitis.  As  before  mentioned,  a  circumvallation  by  adhesions  will  form 
in  those  cases  in  which  only  a  small  quantity  of  infectious  material  has 
escaped.  This  seems  to  be  the  usual  course  of  events.  Occasionally,  hov/- 
ever,  the  inflamed  parts  of  the  appendix  will  first  become  adherent,  and 
then  be  perforated.  In  these  cases  the  alarming  intermezzo  possessing  the 
typical  aspect  of  perforative  peritonitis  will  be  missed,  and  the  abscess  will 
develop  without  a  tendency  to  meteorism  and  collapse,  and  with  a  gradual 
but  steady  growth  of  the  mainly  local  symptoms.     The  complex  of  symp- 


'2m  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

toms  has  little  of  the  character  pertaining  to  peritonitis,  and  resembles 
that  of  an  ordinary  abscess. 

Bv  contiguous  extension,  which  is  mostly  slow,  these  abscesses  may  as- 
sume very  large  proportions.  Neglected  for  a  long  time,  especially  if  they 
are  limited  by  intestines  only,  their  secondary  rupture,  followed  by  a  chill 
and  further  extension,  or  even  their  generalization,  may  occur.  This, 
however,  is  not  common  in  the  early  stages  of  the  process.  The  only  case 
of  this  kind  observed  by  the  author  occurred  nineteen  days  after  the  incep- 
tion of  the  trouble. 

Case. —  IT.  I).,  clerk,  aged  twentv.  Subject  to  alvine  sluggishness,  contracted,  after 
a  more  than  usually  severe  spell  of  constipation,  a  deep-seated,  hard,  painful,  perity- 
phlitic  swelling.  Cathartics  failed  to  relieve  the  bowels,  and,  high  fever  with  vomiting 
having  set  in,  the  author  was  consulted.  Jlay  i,  1878. — Typical  swelling  of  a  cylin- 
drical shape  was  made  out  in  the  right  groin,  and  a  number  of  repeated  large  injec- 
tions of  tepid  water  into  the  gut  were  employed  without  success.  3d. — The  peritoneal 
symptoms,  notably  vomiting,  became  very  distressing,  wherefore  this  therapy  was  aban- 
doned and  opium  treatment  begun.  At  the  same  time  an  ice  bag  was  placed  over  the 
swelling.  The  change  effected  a  decided  improvement  in  the  subjective  symptoms,  but 
the  swelling  continued  to  increase  and  the  fever  remained  unrelieved,  17th. — Spon- 
taneous evacuation  of  a  large,  formed  stool  occurred.  19th. — The  general  condition 
becoming  very  poor,  incision  was  urged,  but  was  firmly  declined  by  patient  and  parents. 
Suddenly,  in  the  night  of  the  same  day.  perforative  symptoms  developed.  The  patient 
died.  May  iOth,  of  septic  peritonitis.  Post-mortem  examination  demonstrated  an  in- 
ternal perforation  of  the  abscess,  and  putrid  septic  peritonitis.  Had  the  patient  con- 
sented to  the  operation,  the  case  might  have  turned  out  differently.  Perforation  took 
place  on  the  nineteenth  day  after  the  invasion. 

Tlie  presence  of  a  tumor,  which  alicay.<  indicates  the  existence  of 
protective  adhesions,  implies  a  certain  amount  of  temporary  security, 
and,  under  certain  circumstances,  may  justify  a  .9hort  delay  of  the 
operation. 

Types  of  Acute  Perittphlitic  Abscess. — Although  the  classification 
of  perityphlitic  abscess  according  to  location  can  not  be  made  with  geomet- 
rical precision,  yet  it  will  be  found  that  most  cases  can  be  naturally  massed 
in  a  series  of  roughly  defined  groups.  The  small  number  of  intermediate 
or  transitory  forms  does  not  vitiate  the  practical  value  of  this  grouping,  upon 
the  right  understanding  of  which  must  be  based  some  important  variations 
of  the  operative  technique. 

It  is  the  author's  wish  to  firmly  maintain  the  importance  of  the  prin- 
ciple that  every  intraperitoneal  abscess  should,  if  possible,  be  opened  and 
drained  without  invading  the  normal  peritoneal  cavity — that  is,  through  ex- 
isting planes  of  adhesion  to  the  parietes.  With  few  exceptions,  all  perity- 
phlitic abscesses  have  .such  an  approachable  side.  To  study,  to  ascertain, 
and  to  utilize  them  is  the  duty  of  the  conscientious  surgeon.  It  is  idle  to 
state  that  safely  incising  and  draining  an  abscess  through  a  laparotomy 
wound — that  is,  through  the  free  peritoneal  cavity — is  an  easy  or  indiffer- 
ent matter,     Xo  competent  person  will  believe  it. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  267 

1.  Ilio-inguinal  Type  {Willard  Parher^s  Abscess). — The  normal  situa- 
tion of  the  caput  coli  and  appendix  vermiformis  near  the  parietes  of  the 
right  iliac  fossa  has  the  consequence  that  the  great  majority  of  circumap- 
])endicular  suppurative  processes  will  naturally  establish  themselves  so  as  to 
have  for  one  of  their  limiting  walls  the  parietal  peritonaeum  of  that  region. 
This  has  led  to  the  erroneous  belief  that  perityphlitic  abscess  is  normally 
located  behind  the  peritoneal  lining  of  the  iliac  fossa. 

This  situation  involves  the  great  practical  advantage  that  the  abscess  can 
be  permitted  to  assume  certain  proportions  so  as  to  render  its  incision  sim- 
ple and  free  from  the  danger  of  invading  the  normal  peritoneal  cavity. 
Therefore,  when  an  immovable  tumor  develops  in  the  right  iliac  fossa  soon 
after  the  inception  of  the  malady,  it  is  safe  to  wait  a  few  days  until  the  ab- 
scess has  assumed  a  certain  size.  On  the  fourth,  fifth,  or  sixth  day  it  may 
be  safely  incised.  Searching  for  pus  with  a  hollow  needle  is  superfluous 
when  the  abscess  is  superficial — that  is,  immediately  beneath  the  parietes  ; 
dangerous  if  it  is  deep-seated,  as  the  gut  might  be  thus  injured  or  the 
healthy  peritonseum  infected. 

Case. — Francisca  Bertrand,  aged  forty-five.  Was  taken  ill  with  fever  early  in  July, 
1882,  and  developed  a  deep  seated,  painful  swelling  in  the  left  iliac  fossa,  with  high 
fever  and  peritonitic  symptoms.  On  the  afternoon  of  August  5th  probatory  puncture 
brought  out  some  pus,  wherefore,  with  the  aid  of  the  family  physician,  Dr.  Assen- 
heimer,  incision  was  jjracticed  by  Hilton's  method.  A  large  quantity  of  pus  escaped, 
and  a  drainage-tube  and  antiseptic  dressing  were  applied.  In  the  following  night  very 
acute  peritonitis  set  in,  to  which  the  patient  succumbed  August  6tli.  No  doubt  the 
retiection  of  the  peritoneum  was  injured,  and  part  of  the  pus  must  have  entered  the 
peritoneal  cavity. 

The  only  safe  way  of  opening  these  abscesses  is  by  methodical  and  care- 
ful dissection,  layer  by  layer  being  divided  by  an  ample  incision  placed 
through  the  longer  axis  of  the  tumor.  The  vicinity  of  pus  will  become 
manifest  by  the  discoloration  and  condensation  of  the  tissues.  When  the 
abscess  is  opened  and  the  bulk  of  its  contents  has  escaped,  a  gentle  ex- 
ploration by  the  index-finger  is  advisable  to  detect  recesses  or  a  foreign 
body.  But  all  rough  treatment  of  the  walls  of  the  cavity  by  scraping, 
tearing,  or  rude  squeezing  is  reprehensible,  as  it  may  lead  to  inward  rupt- 
ure. For  the  same  reason  search  for  and  removal  of  the  ulcerated  or 
necrosed  appendix  from  the  abscess  is  to  be  avoided  as  unnecessary  and 
dangerous.  Two  drainage-tubes  are  slipped  into  the  cavity  and  fastened 
in  the  usual  manner.  They  will  facilitate  irrigation  without  causing  un- 
due distention.  A  daily  change  of  dressings  will  be  required  for  the  first 
week  or  ten  days.  As  soon  as  the  discharge  becomes  scanty  and  serous, 
the  tube  should  be  removed. 

The  ilio-inguinal  type  is  undoubtedly  and  fortunately  the  most  common 
form  of  perityphlitic  abscess,  and  its  time-honored  therapy  as  laid  down  by 
Parker  will  have  to  be  retained  as  safe  and  successful. 

In  sixteen  cases  of  the  ilio-inguinal  group  operated  on  by  the  author  ac- 
cording to  Parker's  plan,  only  one  terminated  fatally,  by  erysipelas.     The 


268  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

patietit  Avjis  under  treatment  for  hip-joint  disease  when,  unfortunately,  the 
complication  with  perityphlitic  abscess  set  in. 

Case. — Ernestine  S.,  servant-irh'l,  aged  nineteen.  Admitted  March  2,  1880,  to  the 
German  Hospital,  with  the  diagnosis  of  hip-joint  disease,  tlie  symptoms  of  which  were 
indubitably  present.  Emaciating  fever,  and  the  characteristic  fle.xion  and  adduction  of 
the  tiiigh,  together  witii  swelling  of  the  gluteal  and  infrapubic  regions,  seemed  to  ad- 
mit of  no  doubt.  Examination  under  ether,  however,  revealed  a  fluctuating  swelling 
of  the  right  groin,  which  yielded  pus  on  puncture,  and  was  incised.  A  large  quantity 
of  pus  and  the  stem  of  an  apple  or  pear  were  evacuated.  Another  incision  below  Pou- 
part's  ligament  establislied  drainage  of  an  abscess  communicating  with  the  perity- 
phlitic gathering.  The  lower  extremity  was  put  into  Buck's  extension,  and  the  cavities 
were  daily  irrigated.  Operative  measures,  directed  against  the  profuse  discharge  from 
the  lower  incision — that  is,  drainage  or  exsection  of  the  hip-joint — were  contemplated, 
when  the  girl  contracted  erysipelas,  and  died  of  it  in  May,  1880.  Post-mortem  exami- 
nation established  the  fact  of  hip-joint  sui)puration,  a  communication  of  the  perity- 
phlitic abscess  with  the  joint  being  found,  by  way  of  the  iliac  bursa. 

See  Case  XI,  page  129,  for  necrosed  appendix  contained  in  inguinal 
hernia. 

2.  Anterior  Parietal  Type. — Next  in  frequency  to  the  ilio-iuguinal  form 
of  perityphlitic  abscess  is  the  type  according  to  which  the  bulk  of  the  puru- 
lent collection  is  found  immediately  behind  the  anterior  abdominal  parietes 
of  the  right  side.  Frequently  this  is  associated  with  a  more  or  less  appar- 
ent ilio-inguinal  tumor,  and  might  be  looked  upon  as  its  extension.  The 
swelling  is  generally  found  behind  the  right  rectus  muscle,  its  shape  verti- 
cally elongated,  its  upper  limit  occasionally  extending  beyond  the  level  of 
the  navel  to  the  hypochondrium,  its  jiroximal  margin  to  or  beyond  the  me- 
dian line.  When  an  unmistakable  continuation  of  the  tumor  can  be  traced 
into  the  right  iliac  fossa,  the  abscess  can  be  safely  opened  above  Poupart's 
ligament,  as  in  the  preceding  grou}).  But  occasionally  the  upper  extension 
will  require  a  separate  incision. 

Case  I. — Abraham  Jacobson,  tailor,  aged  twenty-two.  Perityphlitic  abscess  of  six 
days'  duration,  the  iliac  tumor  extending  inward  and  upward  to  the  inner  margin  of 
the  rectus  muscle,  the  space  above  Poupart's  ligament  feeling  em{)ty.  Norem'ber  19, 
1888. — Typical  incision  at  Mount  Sinai  Hospital,  a  little  below  and  to  the  inward  of 
the  anterior  superior  spine ;  drainage.  Retention  of  pus  in  the  upper  pocket,  hence, 
November  26th,  second  direct  incision.  Rapid  improvement.  January  17th. — Dis- 
charged cured. 

Case  II. — David  Frank,  butcher,  aged  forty-two.  Perityphlitic  abscess  of  eight 
days'  duration  ;  tumor  extended  upward  along  the  line  of  the  rectus  muscle  to  within 
a  hand's  breadth  of  the  costal  margin.  Decemher  8,  1889. — Incision  two  inches  and  a 
half  to  the  inward  of  the  anterior  superior  spine.  Evacuation  of  about  a  quart  of  jms ; 
depth  of  abscess,  twelve  inches;  though  the  wound  was  doing  well,  surgical  delirium 
set  in,  and  the  patient  was  transferred  to  his  home  December  2-4th,  where,  as  his  family 
attendant  reported,  he  soon  recovei-ed  entirely. 

When  it  is  found  that  the  iliac  fossa  is  normal  and  entirely  void  of  re- 
sistance, and  a  circumscribed  tumor  can  clearly  be  felt  some  distance  from 
the  ilium  and  Poupart's  ligament,  it  is  necessary  to  ascertain  where  to  make 


DIAGNOSIS  AND  TEEATMENT  OF  PHLEGMON.  269 

a  safe  incision.  If  the  extent  of  the  tumor  is  great,  a  direct  incision  might 
be  confidently  made.  But  if  the  superficial  extremity  of  the  tumor  is  small, 
it  will  be  safer  to  first  open  the  peritoneal  cavity  in  the  median  line  by  a 
small  incision,  and  digitally  explore  the  exact  relations  and  extent  of  the 
adhesion.  Having  thus  located  the  abscess,  the  exploratory  cut  is  closed, 
and  the  abscess  is  incised  by  a  direct  route. 

Case  I. — Miss  Evelyne  H.,  school-teacher,  aged  twenty-three.  Perityphlitic  ab- 
scess of  two  weeks'  duration.  Small  tumor  to  the  riglit  of  median  line,  underneath  right 
rectus  muscle.  Iliac  fossa  empty.  Per  vaginam^  tumor  was  felt  adherent  to  anterior 
abdominal  wall,  and  with  it  bimanually  movable  backward  and  forward.  March  7, 
1890. — Exploratory  laparotomy  in  median  line  below  the  navel.  Just  to  the  right  of 
incision,  partly  solid,  partly  fluctuating  mass  could  be  felt,  its  walls  being  evidently 
formed  of  intestine,  among  which  the  empty  appendix  was  seen  firmly  attached.  By 
passing  the  finger  aronnd  the  attachment  of  the  tumor  to  the  anteiior  abdominal  wall, 
it  was  found  that  the  iliac  fossa  contained  healthy  intestine,  and  that  the  tumor  was 
in  no  wise  cimnected  with  it.  Fixation  of  tumor  by  fingers  in  abdomen ;  puncture 
through  abdominal  wall ;  fetid  pus.  Closure  of  laparotomy  wound  by  suture.  It  was 
sealed  with  a  strip  of  rubber  tissue  moistened  with  a  little  chloroform.  Incision  of 
abscess  along  the  line  of  puncture  ;  evacuation  of  five  ounces  of  pus.  Uninterrupted 
recovery.     Discharged  cured,  April  10,  1890. 

Case  II. — Mark  Beermann,  hat-maker,  aged  nineteen.  Perityphlitic  abscess  of 
seven  days'  standing.  Somewhat  movable  tumor  underneath  right  rectus  muscle  on  a 
level  witli  umbilicus.  Iliac  fossa  normal.  Novemter  30^  1889. — At  Mount  Sinai  Hos- 
pital, median  exploratory  laparotomy.  Location  of  adhesion,  which  was  very  limited, 
was  established  by  digital  exploration.  Closure  of  laparotomy  wound.  Incision  and 
drainage  of  abscess.     Discharged  cured,  J.-muary  11,  1890. 

Case  III. — Perityphlitic  abscess  of  the  anterior  type  may  extend  to  and  heyond 
the  median  line,  whea  it  icill  hold  close  relations  with  and  may  perforate  into  the 
bladder.  Henry  Marks,  aged  seventeen,  suffered  from  habitual  constipation  and  fre- 
quent attacks  of  colic.  In  June,  July,  and  August,  1878,  severe  attacks  of  colic  were 
noted  and  overcome  by  tJie  use  of  purgatives.  August  25th. — Dr.  L  Weiss,  the  family 
attendant,  made  out  typhlitis  and  ordered  a  laxative,  whicii,  however,  failed  to  relieve 
the  patient.  Thereupon  opium  was  methodically  exhibited  until  September  6th,  when 
the  patient  had  a  spontaneous  and  copious,  formed  evacuation.  Septemler  7th. — The 
temperature  rose  to  104°  Fahr.  ;  the  external  swelling  in  the  right  groin  became  very 
marked.  10th. — The  author  saw  the  patient  in  consultation  with  Dr.  Weiss.  A  uni- 
form puffy  swelling  was  found  occupying  the  right  groin,  and  was  extending  beyond 
the  median  line  of  the  abdomen.  Frequent  urinatiim  distressed  the  patient  a  good  deal, 
who  exhibited  the  usual  hectic  symptoms  of  long-continued  suppuration.  Deep  fluctu- 
ation was  made  out,  and  evacuation  of  the  abscess  was  determined  upon.  The  trans- 
versalis  fascia  being  gradually  exposed,  it  was  found  infiltrated  and  firmly  attached  to 
the  underl^\ing  tissues.  A  probatory  puncture  made  in  the  bottom  of  the  wound,  close 
to  the  OS  ilium,  gave  pus,  wliereupon  the  abscess  was  freely  incised,  and  a  large  quan- 
tity of  matter  was  voided.  No  foreign  body  could  be  found.  Digital  ex])loration  dem- 
onsti-ated  a  long  sinuosity  extending  toward  the  median  line  to  a  pocket  occupying  the 
prevesical  space,  A  drainage-tube  was  placed  in  the  main  abscess,  another  one  was 
carried  into  the  prevesical  space,  and  the  wound  was  dressed  with  carbolized  gauze, 
The  patient's  wretched  condition  at  once  commenced  to  improve ;  appetite  and  sleep 
returned,  and  the  profuse  night-sweats  disappeared.  20th. — The  drainage-tubes  be- 
came disarranged,  and  were  found  slipped  out  of  the  wound      Difficulty  was  experi- 


270  RULES  OF  ASEPTIC  AND   ANTISEPTIC  SURGERY. 

CDced  in  replacing  them,  and  symptoms  of  retention,  witli  renewed  p.iii!  and  fever,  set 
in  again.  2Jd.—The  author  again  saw  the  patient,  and  replaced  tiie  tubes.  A  consid- 
erable quantity  of  pus  was  found  in  the  prevesical  pocket.  From  this  date  on  uninter 
rupted  improvement  was  noted,  and  the  patient  got  up  October  10th.  October  20th, 
the  tubes  were  withdrawn,  and  October  oOth  the  fistula  was  closed. 

In  this  case  iniiniiu'iit  perforation  of  tlie  bladder  wall  was  prevented  by 
timely  incision. 

3.  Posterior  Parietal  Type. — Whenever  perforative  processes  occur  in 
an  appendix  located  near  the  posterior  parietes  of  the  peritoneal  cavity — 
for  instance,  near  the  right  sacro-iliac  synchondrosis  of  the  lumbar  region — 
the  resulting  abscess  will  naturally  have  a  deep  situation.  Cases  w\\\  occur 
in  which  incision  of  such  an  abscess  can  not  be  made  unless  it  be  done 
through  a  laparotomy  wound.  But  there  can  be  no  doubt  that  in  a  certain 
proportion  of  these  cases  a  safe  incision  may  be  made  from  behind. 

Case  I. — Tames  Solomon,  school-boy,  aged  thirteen.  April  i5,  18S9. — Perityphli- 
tis of  five  days'  standing.  In  consultation  with  Dr.  W.  Morse,  an  indistinct,  very  deep- 
seated,  and  painful  tumor  was  felt  in  the  region  of  the  sacro-iliac  juncture  «.f  the  right 
side.  By  April  22d  the  tumor  had  considerably  enlarged,  and  seemed  to  lie  just  be- 
neath the  right  rectus  muscle.  At  Mount  Sinai  Hospital  laparotomy  was  done  the 
same  day  over  tlie  site  of  the  swelling,  which  was  found  to  hold  no  connection  what- 
ever with  the  anterior  abdominal  wall,  but  wns  firmly  adherent  to  the  posterior  wall 
of  the  pelvis.  The  ascending  colon  formed  the  outer  wall  of  the  tumor.  The  appen- 
dix could  nowliere  be  found,  and  was  undoubtedly  imbedded  in  the  mass  of  the  tu:nor. 
The  anterior  wound  was  closed,  and  a  long,  hollow  needle  was  thrust  into  the  region  of 
the  tumor  from  behind,  entering  the  pelvis  a  little  to  the  inward  of  the  line  of  the  pos- 
terior superior  spine,  its  direction  being  downward  and  forward.  Pus  was  gained  at 
great  depth,  and  tlie  abscess  was  incised  and  drained  from  there  by  a  rather  long  and 
deep  incision.  All  the  febrile  symptoms  disappeared,  and  the  boy  was  discharged  cured, 
June  8,  1889. 

Case  II. — Sanniel  Gross,  tailor,  thirty-three  years  old.  Was  laparotomized  at 
Mount  Sinai  Ho.spitai,  January  27,  1889,  for  internal  obstruction  of  six  days'  standing. 
Fecal  vomiting  was  present,  with  enormous  tyiupanites  due  to  intestinal  paralysis. 
The  cause  of  the  obstruction  was  found  in  a  very  long  and  much  distended  appendix 
vermiformis,  the  apex  of  which  was  firmly  attached  to  the  under  surface  of  the  right 
half  of  the  transverse  mesocolon.  Tlirough  the  loop  thus  formed  about  three  leet  of 
the  ileum  had  slipped  ami  had  become  strangulated.  Corresponding  to  the  attaciiment 
of  the  apex  of  the  appendix  a  massive  swelling  was  felt,  occupying  the  spa'i-e  beliind 
the  colon,  and,  when  the  adliesiou  was  severed,  pus  welled  up  from  a  small  aperture 
correspondin  r  to  the  site  of  the  attachment.  This  led  into  an  abscess  cavity  wliich 
was  carefully  evacuated.  The  appendix  being  removed,  the  intestines  were  reidacecl 
with  considerable  difficulty.     The  patient  died  an  hour  and  a  half  after  the  operation.* 

Case  III. — Mr.  M.  C,  aged  sixty-two.  Had  been  suffering  from  habitual  and  very 
obstinate  constipation  for  years.  In  May,  1880,  profuse  diarrhoea  set  in,  and  ccuid  not 
be  controlled  by  any  of  the  usual  dietetic  and  therapeutic  measures.  A  grave  deterio- 
ration of  the  general  condition  developed,  and  the  patient  lost  very  much  flesh  in  spite 
of  forced  feeding.  August  31st. — Fever  set  in,  and  the  presence  of  a  painful  swelling 
in  the  iliac  fossa  was  made  out.     September  3d. — The  author  saw  the  case  in  consulta- 

*  For  complete  history,  see  "  New  York  Medical  Journal,"    May  4,  1889,  p.  478. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  211 

tion  with  Dr.  W.  Balser  and  Dr.  L.  Conrad.  A  large  fluctuating  swelling  occupied  the 
right  half  of  the  pelvis,  and  tympanitic  percussion  sound  was  noted  in  tlie  lumbar  re- 
gion. Two  incisions  were  made — one  above  Poupart's  ligament,  another  in  the  lum- 
bar region — and  an  enormous  amount  of  gas,  pus,  and  fecal  matter  was  evacuated. 
Profuse  secretion  and  diarrhoea  continued,  and  tlie  patient  died  September  22d.  Fost- 
moi'tem  examination  revealed  a  tight  cancerous  stricture  of  the  ileo-csecal  valve,  and 
an  enormous  dilatation  of  the  lower  portion  of  the  ileum,  which  resembled  thick  gut. 
Large  masses  of  impacted  fecal  matter  were  found  in  this  poucb,  which  was  adherent 
to  the  posterior  parietal  peritonaeum,  and  was  freely  communicating  through  a  number 
of  ulcerous  defects  with  the  abscess  caviiy. 

4.  Rectal  Type. — It  is  a  good  rule  never  to  neglect  to  examine  the  rec- 
tum of  a  patient  suffering  from  perforative  appendicitis.  A  long  appendix 
may  become  fixed  and  perforated  in  the  small  pelvis,  and  an  abscess  is  then 
apt  to  develop  in  close  vicinity  to  the  rectum,  whence  it  can  be  safely  opened 
and  evacuated.  The  objection  that  faeces  might  enter  the  abscess  has  thus 
far  not  been  verified  by  experience. 

Case. — August  Petry,  clerk,  aged  eighteen.  Was  admitted,  November  10,  1887,  to 
the  German  Hospital  with  symptoms  of  perforative  peritonitis.  General  tympanites 
prevailed,  and  a  tumor  could  not  be  felt  anywhere,  but  intense  pain  v/as  complained  of 
on  pressure  in  the  right  iliac  fossa.  The  poor  state  of  the  patient  forbade  operative  in- 
terference, and  opiates  and  stimulants  were  exhibited.  By  November  13th  the  patient 
had  fairly  rallied.  An  examination  of  the  rectum  disclosed  the  presence  of  a  fluctu- 
ating swelling  corresponding  to  its  anterior  wall.  An  incision  evacuated  a  large  mass 
of  pus,  and  a  drainage-tube  was  placed  into  the  cavity  and  brought  out  tlirough  the 
anus.  The  tube  was  not  borne  well.  It  excited  tenesmus,  and  was  repeatedly  ex- 
pelled. As  the  patient  was  doing  very  much  better,  and  the  tumor  had  disappeared, 
it  was  left  off  without  ill  consequences.  The  patient  was  discharged  cured  November 
27,  1887. 

5.  Mesocodiac  Tyi^e. — To  characterize  that  most  serious  form  of  circum- 
appendicular  abscess,  the  walls  of  which  are  composed  entirely  of  aggluti- 
nated intestines,  and  which  hold  no  immediate  relation  whatever  with  the 
parietes  of  the  abdominal  cavity,  the  term  ''  mesocoeliac  "  was  chosen 
(from  at  KoiXCai,  the  intestines,  and  iv  fiea-io,  between).  The  abscess  is  found 
occupying,  as  it  were,  the  middle  of  the  peritoneal  sac.  Hence,  to  reach 
and  evacuate  this  form  of  abscess,  the  free  peritoneal  cavity  must  be  opened, 
and  the  collection  of  pus  must  be  reached  by  separating  the  adherent  coils 
of  gut  which  inclose  it. 

We  owe  the  development  of  the  teclmiqiie  of  the  evacuation  of  these 
abscesses  mainly  to  McBurney,  whose  procedure  is  as  follows  :  A  longi- 
tudinal incision,  as  for  simple  appendicitis,  is  made  parallel  to  and  along 
the  outer  border  of  the  right  rectus  muscle.  The  abnormal  cohesion  and 
resistance  of  the  implicated  intestines  will  point  out  the  site  of  the  abscess. 
The  protruding  normal  coils  of  gut  should  be  packed  away  under  a  pro- 
tective bulwark  of  sponges  held  in  situ  by  the  assistants'  hands,  so  that,  if 
the  abscess  is  opened  unawares,  no  pus  should  soil  the  healthy  peritonteum. 
Two  of  the  nearest  coils  are  now  gently  and  cautiously  separated  by  gradual 
traction,  exercised  by  the  operator's  fingers,  until  a  small  quantity  of  pus  is 


272  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

seen  exuding.  It  is  desirable  to  let  the  pus  escape  slowh',  so  as  to  have  am- 
ple time  to  sponge  it  away  as  it  pours  out ;  otherwise  the  whole  tield  might 
be  overwhelmed  and  contaminated  by  a  sudden  flood  of  matter. 

Note  — It  seems  that  exhausting  the  abscess  through  a  small  aperture  bv  means  of  a  syringe 
would  be  an  improvement  upon  the  mopping  up  by  sponges. 

As  soon  as  the  bulk  of  })us  has  been  removed,  the  cavity  is  wiped  out 
clean  with  sponges  dipped  in  an  antiseptic  solution,  and  now  the  adherent 
intestines  are  still  more  separated  to  permit  the  surgeon  to  inspect  its  in- 
terior. If  the  appendix  is  loose  and  easily  to  be  got  at,  it  can  be  removed, 
but,  if  it  is  found  closely  adherent  and  very  brittle,  it  is  better  to  remove 
only  so  much  of  it  as  will  come  away  easily.  A  good-sized  drainage-tube  is 
placed  into  the  bottom  of  the  cavity,  which  is,  in  addition,  loosely  filled  with 
strips  of  iodoform  gauze.  These  and  tlie  rubber  tube  are  brought  out  near 
the  lower  angle  of  the  wound,  and  the  abdominal  incision  is  closed  in  the 
usual  manner.  If  the  case  is  progressing  well,  the  packing  can  be  with- 
drawn on  the  third  day,  as  by  that  time  protective  adhesions  will  have  formed 
between  the  adjoining  coils  of  gut.  The  drainage-tube  is  to  be  removed  as 
soon  as  the  secretions  become  serous  and  scanty. 

c.  Chroxic  or  Relapsixg  Appendicitis  axd  Perityphlitic  Ab- 
scess.— It  was  shown  how  simple  catarrhal  conditions  of  the  mucous  lining 
of  the  appendix  may  lead  to  more  or  less  complete  occlusion  of  the  exit  of 
this  viscus.  The  retention  of  the  secretions  will  then  cause  distention  and 
the  train  of  symptoms  characteristic  of  appendicitis.  With  the  diminution 
of  the  catarrhal  swelling  of  the  mucous  membrane,  a  restitution  ad  inte- 
grum will  take  place.'  Usually  the  symptoms  produced  by  this  form  are 
mild  and  tractable.  Bland  laxatives  and  opiates,  rest  in  bed,  with  some 
form  of  local  applications,  generally  bring  about  a  lasting  recoverv. 

Where  ulceratvie  ])rocesses,  prolonged  inflammation,  or  the  doubling 
of  the  appendix  upon  itself,  have  caused  the  formation  of  cicatricial  mat- 
ter— hence  permanent  stenosis  of  greater  or  less  intensity — the  recurrence 
of  severe  obstructive  symptoms  will  be  more  frequent,  the  intervals  between 
the  attacks  shorter  and  shorter,  and  the  tendency  to  the  formation  of  adhe- 
sions more  pronounced.  Tims  the  ver}"  chronicity  of  the  process  will  yield, 
in  its  tendency  to  the  formation  of  adhesions,  a  certain  protective  charac- 
ter. Should  perforation  occur,  these  adhesions  fulfill  a  most  important 
function  in  preventing  general  septic  peritonitis.  The  number  of  relapses 
of  appendicitis  may  be  very  great ;  in  one  of  the  author's  cases  sixteen  were 
counted.  With  the  increase  of  the  cicatricial  stenosis,  the  formation  of 
concretions,  and  the  loss  of  contractile  power  of  the  appendix,  tlie  tend- 
ency to  ulcerative  or  gangrenous  lesions  becomes  more  and  more  pronounced, 
and  finally  culminates  in  perforation. 

As  we  have  no  means  of  ascertaining  the  exact  condition  of  the  ajipen- 
dix,  frequent  recurrence  and  increasing  severity  of  the  disorder  clearly  justify 
an  attempt  at  its  removal.  The  term  "  attempt "  is  used  here  purposely  to 
signify  that  such  endeavors  may  occasionally  be  baffled  by  intricate  and 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  273 

close  adhesions,  which  a  prudent  surgeon  may  prefer  not  to  disturb  for  fear 
of  lacerating  the  gut.  It  may  be  said,  however,  that,  should  the  first 
attempt  fail,  a  second  one  may  be  crowned  with  success.* 

All  surgeons  admit  the  occurrence  of  the  spontaneous  evacuation  of  peri- 
typhlitic  abscesses  into  an  adjoining  part  of  the  gut.  Occasionally  perfora- 
tions into  the  bladder,  rectum,  or  even  the  pleura,  have  been  observed  and 
described.  If  such  an  evacuation  into  the  gut  is  followed  by  a  perfect  oblit- 
eration of  the  cavity  and  fistula,  no  relapse  will  occur.  Should  evacuation 
be  imperfect,  ins23issation  of  the  retained  pus  and  a  temporary  dormancy  of 
the  acute  signs  of  the  process  will  result,  until  some  local  irritation  again 
provokes  rapid  intumescence,  followed  by  evacuation  of  the  surplus  con- 
tents of  the  abscess.  This  process  may  be  repeated  a  number  of  times,  as  a 
result  of  which  a  thick  mass  of  cicatricial  matter  will  be  deposited  around 
the  focus.     Cases  of  this  order  demand  surgical  interference. 

Case. — Miss  Caroline  D.,  aged  fourteen.  Bad  had  within  two  years  three  attacks 
of  perityphlitis  with  well-marked  ilio-inguinal  tumor,  which  never  disappeared  com- 
pletely. On  April  24,  1888,  Dr.  L.  Arcularius  presented  her  to  the  author,  who  ad- 
vised an  operation.  A  small  immovable  tumor  could  be  felt  occupying  the  iliac  fossa. 
On  May  1,  1888,  an  incision  was  made,  and  a  small  cavity  of  the  size  of  a  chestnut  was 
laid  open.  Its  walls  consisted  of  a  massive  deposit  of  cicatricial  matter,  its  contents  of 
a  putty-like  mass  of  inspissated  pus,  surrounded  by  a  coating  of  deciduous  granulations. 
"When  all  the  soft  matter  was  scooped  out,  a  narrow  sinus  was  traced  to  a  depth  of  an 
inch  and  a  half  beyond  the  bottom  of  the  cavity.  The  wound  was  packed,  and  was 
kept  open  witli  considerable  difficulty  during  the  entire  summer,  small  quantities  of 
feculent  matter  escaping  from  time  to  time.  In  the  course  of  the  following  winter  the 
tumor  gradually  shrank  away,  the  discharge  dried  up,  and,  the  tube  being  removed,  per- 
manent healing  took  place. 

Had  the  outer  opening  been  permitted  to  heal,  recurrence  of  the  abscess 
would  have  probably  followed,  as  closure  of  the  communication  with  the 
gut  came  about  with  a  great  deal  of  hesitancy.  The  same  state  of  affairs 
may  and  does  often  prevail  in  abscesses  that  are  evacuated  by  the  surgeon, 
and  in  which  the  outer  opening  shows  a  more  pronounced  tendency  to  clos- 
ure than  the  sinus  leading  from  the  abscess  cavity  to  the  gut.  Thus  the 
presence  of  a  however  minute  fecal  fistula  that  has  not  healed  soundly  may 
bring  about  a  number  of  recurrences  in  the  tract  of  the  old  abscess.  It 
stands  to  reason  to  say  that  inadequacy,  both  as  regards  the  quality  and  dura- 
tion of  drainage  of  the  abscess  cavity,  has  a  most  important  influence  upon 
the  retardation  of  the  closure  of  the  fecal  sinus.  Hence  the  tendency  to 
relapses  will  be  very  pronounced  in  cases  where  evacuation  of  the  primary 
abscess  took  jolace  spontaneously. 

Case. — Frank  Kennedy,  printer,  aged  twenty-five.  Had  suffered  since  childhood 
from  a  number  of  attacks  of  smart  pain  in  the  right  groin  accompanied  by  fever.  In 
the  early  part  of  1885  he  acquired  an  oblique  inguinal  hernia  of  the  right  side,  and  w.is 

*  I  take  the  Ubcrty  of  referring  to  a  verbal  communication  of  Dr.  F.  Lange,  who  informed 
me  that  he  once  had  to  abstain  from  removing  the  appendix  through  an  anterior  incision.  Later 
on  the  organ  was  successfully  removed  through  a  posterior  wound. 


274  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

ordered  to  wetir  a  truss,  the  pressure  of  which,  if  the  pad  became  displaced  outward, 
caused  iuteuse  suftering,  so  tliat  he  had  to  abandon  its  use  from  time  to  time.  In  June, 
1885,  during  a  severe  attack  of  lever,  an  abscess  broivC  open  two  inches  and  a  half 
below  the  anterior  superior  spine.  Since  then  healing  and  reopening  of  the  sinus  had 
occurred  four  times.  On  March  3,  1886,  a  dense  deep-seated  tumor  could  be  felt  in 
the  right  groin,  independent  of  the  hernia,  which  could  be  easily  replaced.  Follow- 
ing the  existing  sinus,  the  center  of  the  indurated  mass  was  laid  open  by  a  large  incis- 
ion running  parallel  with  Poupart's  ligament.  At  the  depth  of  two  inclies  a  globular 
stiiootli-walled  cavity  was  exposed,  within  Avhich,  imbedded  in  frail  granulations,  a 
stratitied  coprolithon  of  the  size  of  an  unshelled  almond  was  found.  A  channel  of  the 
diameter  of  a  goose-quill  was  seen  leading  from  this  cavity  inward  and  downward,  into 
which  could  be  slipped  twelve  inches  of  a  slender  drainage-tube.  When  water  was 
thrown  in  through  this  tube,  diluted  fecal  matter  regurgitated.  Under  the  microscope 
this  matter  w^as  seen  containing  granules  of  amylum  and  fat  with  fat  crystals  arranged 
in  the  shape  of  sheaves.  The  wound  was  kept  packed  with  gauze  till  March  25th,  and 
was  healed,  seemingly  from  the  bottom,  by  April  Uth.  On  November  15,  1886,  the 
fistula  reopened,  and  the  proposition  was  made  to  the  patient  to  expose  the  site  of  the 
fecal  sinus  from  within  by  laparotomy,  and  to  deal  with  it  by  extirpation  of  the  appen- 
dix or  enterorrhaphy.  He  declined  to  take  the  risk,  and  preferred  to  wear  a  tube  per- 
manently. Sparse  quantities  of  a  feculent,  orange- colored  serum  continued  to  escape 
from  time  to  time  until  the  end  of  1888,  when  the  tube  could  not  be  replaced  once, 
and  was  abandoned.     As  it  seems,  permanent  healing  tlien  took  place. 

The  proposition  made  to  this  patient,  to  close  his  fecal  fistula  by  laparot- 
omy and  an  ai)propriate  dealing  with  the  involved  gut,  contains  the  essence 
of  a  plan  the  adoption  of  which  might  be  necessary  in  order  to  bring  about 
the  speedy  cure  of  an  apparently  interminable,  most  disagreeable,  and  loath- 
some ailment.  But  the  necessity  for  the  adoption  of  such  extreme  measures 
must  be  very  rare  indeed. 

On  the  whole,  it  may  be  said  that  the  recurrence  of  an  evacuated  peri- 
typhlitic  abscess  is  comi)aratively  rare,  and  that,  if  it  is  due  to  the  presence 
of  a  fecal  fistula,  its  lasting  cure  can  in  most  instances  be  effected  by  pro- 
longed and  efficient  drainage  of  the  outer  wound. 

Another  cause  of  prolonged  suppuration  within  and  around  an  incised 
perityphlitic  abscess  is  the  formation  of  one  or  more  extraperitoneal  bur- 
rows and  cavities,  located  between  the  several  layers  of  the  abdominal  wall, 
which  are  the  direct  consequence  of  inadequate  measures  at  drainage.  The 
primary  cause  of  the  abscess  may  be  eliminated,  the  perforative  aperture 
of  the  appendix  or  gut  may  long  since  have  permanently  closed,  and  yet 
frequent  relapses  of  suppuration  will  keep  the  patient  confined  to  the 
bed.  How  to  deal  with  a  case  of  this  kind  may  be  seen  from  the  following 
history  : 

Mrs.  E.  T.,  aged  thirty-two.  "Was  operated  for  perityphlitic  abscess  by  a  prominent 
gynecologist  of  this  city  in  the  latter  part  of  the  summer  of  1887.  Four  weeks  after 
the  operation  the  drainage-tube  was  withdrawn,  and  the  wound  healed  promptly,  but 
a  reaccumulation  and  evacuation  of  pus  soon  followed,  and  symptoms  of  recurrent  re- 
tention were  observed  on  an  average  every  four  or  six  weeks  until  January  13,  1889, 
when,  by  the  same  practitioner,  bloody  dilatation  was  done  with  the  confident  expecta- 
tion of  lasting  success.     These  hopes,  however,  remained  unfulfilled.     Up  to  March  1, 


DIAGNOSIS  AND  TEEATMENT  OF  PHLEGMON.  275 

1889,  three  more  recrudescences  occurred  which  were  closely  observed  by  the  author. 
Each  time  symptoms  of  retention  were  present,  though  a  large  and  long  drainage-tube 
was  constantly  in  situ,  reaching  to  the  bottom  of  the  wound.  Circumscribed  swellings 
occurred  then  once  above,  another  time  to  the  inner  side  of  the  sinus,  and  pus  was  seen 
welling  up  on  pressure  from  tlie  drainage-tube.  It  was  decided  to  tind  and  remove  the 
cause  of  this  distressing  condition  by  an  operation,  which  was  done  March  11,  1890,  in 
the  presence  of  Dr.  Lange  and  Dr.  Bull,  of  this  city.  The  tract  within  which  had  lain 
the  drainage-tube  was  exposed  to  its  bottom  by  an  incision  nine  inches  long,  and  run- 
ning parallel  with  Poupart's  ligament.  Carefully  examined,  it  was  found  to  be  soundly 
and  firmly  closed  at  the  bottom,  no  manner  of  communication  existing  with  the  gut, 
though  it  was  evident  that  only  a  thin  layer  of  tissue  separated  the  cavity  from  the 
peritoneal  sac.  On  the  lateral  aspect  of  the  smooth  lining  of  the  old  drainage  track, 
and  not  far  from  the  bottom,  two  minute  apertures  were  seen  inosculating,  into 
which  the  probe  passed  for  a  distance  of  two  and  four  inches,  respectively,  the  longer 
track  leading  toward  the  navel,  the  shorter  upward  toward  the  crest  of  the  ilium. 
When  these  narrow  tracts  were  slit  up,  each  of  them  was  found  terminating  in  a  small 
pocket  containing  granulations  and  pus.  These  sinuses  were  located  within  the  ab- 
dominal parietes,  between  the  muscular  and  peritoneal  layers.  Unavoidably,  the  peri- 
toneal cavity  was  opened  in  two  places,  but,  as  no  tumor  could  be  felt  within,  these 
apertures  were  not  enlarged.  However,  a  long  probe  was  passed  into  Douglas's  cul- 
de-sac  through  one  of  these  apertures,  where  a  finger  placed  in  the  vagina  could  dis- 
tinctly feel  its  rounded  point.  The  very  large  wound  was  purposely  left  open,  and 
the  dressing  consisted  in  an  iodoform-gauze  packing,  which  was  renewed  every 
twenty-four  hours  in  the  beginning,  later  on  at  longer  intervals.  Uninterrupted  heal- 
ing followed,  though  it  took  a  long  time  on  account  of  the  size  of  the  wound.  June 
3d. — The  patient  was  discharged  cured,  and  has  remained  well  ever  since  then. 

Conclusions. — 1.  Mild,  presumably  catarrhal,  forms  of  appendicitis, 
require  no  operative  measures,  but  dietetic  and  medicinal  treatment  by 
opiates,  laxatives,  rest,  and  local  applications. 

2.  The  more  severe  and  persistent  forms  of  appendicitis  may  render  ex- 
cision of  the  appendix  advisable,  especially  if  frequent  recurrence,  with 
increase  of  the  violence  of  the  symptoms,  is  observed. 

3.  Most  perityphlitic  abscesses  hold  close  relations  with  one  or  another 
of  the  abdominal  parietes.  The  location  of  the  parietal  adhesions  of  the 
abscess  is  to  be  first  ascertained,  if  necessary,  by  exploratory  laparotomy, 
and  the  abscess  is  to  be  then  incised  and  drained  through  the  area  of  adhe- 
sion, thus  avoiding  infection  of  the  sound  peritonaeum. 

4.  Perityphlitic  abscesses  that  possess  no  parietal  adhesions  and  have 
a  mesocoeliac  situation  between  free  coils  of  intestine  must  be  reached  by 
laparotomy  through  the  uninvolved  peritoneal  cavity.  Precautions  have  to 
be  taken  not  to  infect  the  normal  peritongeum. 

5.  Eecurrence  of  suppuration  in  the  groin,  following  spontaneous  or 
artificial  evacuation  of  a  perityphlitic  abscess,  may  be  due  either  to  the  per- 
sistence of  a  small  fecal  fistula,  or  to  the  presence  of  secondary  intraparietal 
sinuses  caused  by  inadequate  drainage  and  retention. 

In  the  first  case  prolonged  and  efficient  drainage  is  to  be  employed  for 
a  long  time  before  resorting  to  artificial  closure  of  the  fecal  fistula  by  lapa- 
rotomy and  enterorrhaphy  or  otherwise. 

37 


278  RULES  OF   ASEPTIC   AND   ANTISEPTIC  SURGERY. 

In  the  second  case  all  sinuses  and  pockets  have  to  be  found  by  free  and 
careful  dissection,  and,  when  they  have  been  slit  up  and  scraped,  the  wound 
is  to  be  treated  by  the  open  metliod  to  effect  a  sound  cure. 

g.  Abscess  of  the  Liver. — The  diagnosis  of  hepatic  ab.-cess  is  based 
upon  the  presence  of  a  painful  and  growing  intumescence  of  the  liver,  ac- 
companied by  more  or  less  intense  fever,  which  gradually  assumes  a  hectic 
character.  In  the  beginning  the  swelling  ascends  and  descends  at  respira- 
tion ;  but  later  on,  when  the  liver  becomes  attached  to  the  abdominal  wall, 
this  mobility  disappears.  Probatory  puncture  with  a  fine  aspirating  needle 
can  be  safely  made,  and  will  generally  dispel  any  doubt.  As  soon  as  the 
diagnosis  is  secured,  incision  has  to  be  made. 

Where  adhesion  of  the  hepatic  swelling  to  the  abdominal  wall  is  estab- 
lished, or,  even  more  so,  where  the  suppurative  process  has  involved  the 
integument,  a  free  incision  can  be  safely  made.  A  large-sized  drainage-tube 
should  be  inserted  into  the  cavity,  and  frequent  irrigation  should  be  em- 
ployed.    The  wound  is  covered  with  an  ample  moist  dressing. 

The  incision  of  hepatic  abscesses  located  in  the  unattached  liver  require 
some  si^ecial  precautions.  The  abdominal  wall  opposite  the  tumor  is  incised 
under  a  strict  observance  of  the  rules  laid  down  for  laparotomy,  so  as  to 
expose  the  liver.  The  incision  is  packed  with  iodoformed  gauze,  and  a  dry 
dressing  is  applied. 

In  three  days  firm  adhesions  of  the  liver  to  the  abdominal  wall  will  be 
established,  when,  the  packing  being  removed,  the  liver  is  punctured,  and, 
pus  being  found,  is  freely  incised  and  the  cavity  evacuated  and  drained. 

Ji.  Lumbar  Abscesses. — The  significance  of  acute  lumbar  abscesses  de- 
pends upon  their  causation  and  upon  the  locality  from  which  they  take 
their  origin.  The  majority  of  lumbar  abscesses  are  caused  by  purulent 
affections  of  the  kidney  or  its  pelvis — as,  for  instance,  by  renal  calculus 
or  pyelitis — but  in  a  com})arative]y  large  number  of  cases  no  affection  of  the 
kidneys  or  their  adnexa  can  be  recognized,  and  traumatism  of  one  or  another 
kind  must  be  assumed  as  the  causative  agent. 

Contusion  and  a  sudden  and  unexpected  strain  of  the  back  were  stated 
to  the  author  by  patients  as  causative  factors.  The  beginnings  of  lumbar 
abscess  are  always  obscure  and  insidious.  A  deep-seated  unilateral  pain  in 
the  small  of  the  back  is  first  complained  of.  One  or  more  chills  or  a  low 
form  of  hectic  fever  set  in.  The  patient's  back  is  bent  upon  the  affected 
side,  and  is  more  or  less  tender.  Loss  of  vigor  and  emaciation  become  more 
and  more  evident,  until  a  distinct  tumor,  marked  by  dullness  on  percussion, 
can  be  made  out  in  the  space  between  the  crest  of  the  ilium  and  the  twelfth 
rib.  The  way  of  extension  of  the  abscess  is  prescribed  by  the  quadratus 
lumborum  muscle,  the  outer  edge  of  which  serves  as  a  landmark  for  finding 
and  incising  it.  The  presence  of  pyelitis  or  pyonephrosis,  ascertained  by 
examination  of  the  urine,  is  very  significant,  and  possible  doubts  as  regards 
the  nature  of  the  trouble  may  be  dispelled  by  one  or  more  probatory  punct- 
ures with  a  well-disinfected  hollow  needle  and  the  aspirator.  A  good-sized 
caliber  should  be  selected,  as  grumous  or  flocculent  pus  is  apt  to  clog  a 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON. 


277 


Fig.  1S4. — Lange's  position  for  renal  and  perinepiiric 
operations. 


small-sized  needle,  aud  a  negative  result  may  be  arrived  at  in  the  presence 
of  a  large  collection  of  matter. 

Case. — Mr.  I.  A.,  brewer,  aged  twenty-two,  developed  lumbar  pain  and  swelling 
of  the  right  side  without  any  known  cause.  April  17,  1881. — High  fever  accompanied 
the  seizure,  and,  though  no  fluctuation  could  be  felt,  the  diagnosis  of  perinephritic 
abscess  was  made.  April  21st. — In  the  presence  of  Dr.  Heppenheimer,  the  family  phy- 
sician, four  probatory  punctures  were  made  with  an  aspirator  needle  without  positive 
result,  and,  unfortunately,  the  contemplated  incision  was  deferred  until  the  next  day. 
when  perforation  into  the  pleura  and  rapidly  fatal  pyothorax  developed. 

Had  a  larger-sized  needle 
been  used,  pus  would  have 
been  found,  and  the  fatal 
termination  might  have  been 
averted  by  timely  incision. 

Early  incision  can  never 
do  any  harm  where  perine- 
phritic abscess  is  suspected, 
and  will  be  of  some  use  even 
if  pus  be  not  found  at  the 
first  attempt.  On  account 
of  the  deep  situation  of  the 
abscess,  and  tiie  necessity  of 
exploring  its  interior  for  sinuosities,  which  may  require  separate  drainage, 
an  ample  incision  is  advisable.  It  should  be  done  in  anaesthesia  under 
strict  antiseptic  precautions,  and  by  gradual  dissection. 

The  patient  is  brought  into  the  position  recommended  by  Dr.  F.  Lange 
for  nephrotomy.  A  roll  made  of  a  blanket  is  slipped  under  the  lumbar  re- 
gion, and  the  body  is  placed  semi-prone 
upon  the  affected  side,  as  shown  in  the 
accompanying  cut  (Fig.  184).  The  vicin- 
ity of  the  swelling  is  carefully  cleansed  and 
disinfected,  and  the  surrounding  parts  of 
the  body  are  protected  with  rubber  cloths 
and  towels  in  the  usual  manner.  A  lon- 
gitudinal incision  two  or  three  inches  in 
length  is  made,  commencing  about  an  inch 
below  the  last  rib,  and  extending  to  near 
the  crest  of  the  ilium,  and  is  gradually 
deepened  until  the  abdominal  muscles  are 
all  divided.  Frequently  pus  will  be  reached 
before  the  edge  of  the  quadratus  lumborum 
muscle  is  exposed.  Should  this  not  be  the 
case,  a  grooved  director  may  be  inserted  un- 
derneath the  external  margin  of  this  muscle, 

and,  being  pushed  downward  and  toward  the  median  line,  will  soon  enter  the 
abscess.     A.&  soon  as  pus  is  seen  to  appear  in  the  groove  of  the  instrument. 


Fig.  1 


-Incising  perinephritic 
abscess. 


278 


RULES  OF   ASEPTIC   AND   ANTISEPTIC  SURGERY. 


Fig.  186. — Arrangement  of  drainage-tubes  for  perinephritic  or  any 
other  deep-seated  and  large  abscess  cavity. 


a  dressing-forceps  is  insinuated  into  tlio  ctivity,  and  is  withdrawn  while  licld 
wide  open.  Blunt  dilatation  of  this  kind  can  be  repeatedly  practiced  until 
the  aperture  is  large  enough  to  admit  the  index-finger  for  exploration. 

Should  the  abscess  contain  urinous  matter  or  stones,  or  should  the  septa 
of  the  calices  of  the  renal  pelvis  be  recognized  by  touch,  the  causation  of 
the  process  by  perforation  outward  from  a  sujipurating  kidney  will  suffer 
no  doubt.  If  found,  stones  may  be  then  extracted,  and  the  cavity,  being 
well  washed  with  boro-salicylic  lotion,  is  drained  by  the  insertion  of  one  or 
more  stout  rubber  tubes. 

Note. — A  very  efficient  mode  of  draining  is  the  following  one :  A  number  of  fenestra  are 
cut  into  the  sides  of  a  large-calibered  rubber  tube,  which  is  placed  well  within  the  cavity.  An- 
other smaller-sized  tube  of 
the  same  length  is  pro- 
vided with  a  couple  of 
fenestra  near  its  mesial 
end,  and  is  inserted  into 
the  abscess  alongside  of 
the  larger  tube  (Fig.  186). 
A  stream  of  lotion  inject- 
ed into  the  smaller  tube 
will  enter  the  bottom  of 
the  abscess,  will  wash  out 
its  recesses,  and  will  carry 
away  secretions  and  debris 

through  the  many  fenestra  of  the  larger  tube.  Safety-pins  thrust  through  the  distal  ends  of  the 
tubes  will  prevent  their  being  lost  in  the  abscess.  An  ample  antiseptic  moist  dressing  should 
envelop  the  entire  lumbar  region,  and  the  patient  should  be  brought  to  bed. 

Aside  from  lumbar  abscesses  of  renal  origin  collections  of  pns  must  be 
mentioned  that  depend  upon  an  extension  into  the  circumrenal  tissue  of 

purulent  processes  originally 
established  elsewhere.  Peri- 
typhlitic  abscess,  empyema, 
perimetritic  suppuration,  and 
finally  cold  abscesses  due  to 
spinal  disease,  belong  to  this 
order. 

Lumbar  abscesses,  the  rela- 
tion of  which  to   purulent  af- 
fections of  the   kidneys  is  un- 
likely   or    doubtlessly    absent, 
admit  of  a  much  better  prognosis.     They  are  frequently  referred  by  the 
patients  to  traumatisms,  and,  properly  incised,  heal  very  promptly. 

Ca.se. — A.  F.,  pawnbroker,  aged  twenty-fonr.  sustained,  in  May,  1885,  in  jumping 
and  slipping,  a  severe  strain  of  the  left  side  of  the  small  of  the  back,  which  was  fol- 
lowed by  sharp  pain  and  stiffness  for  a  few  days.  It  subsided  spontaneously,  but  left 
behind  a  soreness  of  varying  intensity.  May  20^  1886  — Fever  set  in  with  intense  lum- 
bar pain,  but  swelling  came  on  very  slowly.  Though  looked  for,  it  could  not  be  made 
out  until  July  10th,  wlien  Dr.  E.  Schwedler  ascertained  its  presence.     The  kidneys. 


Fig.  187. — Dressing  tor  kiinbar  or  hepatic  absces 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  279 

gut,  and  spinal  column  were  found  normal.  July  12th. — Incision  by  gradual  dissection 
was  practiced  under  ether.  The  abdominal  muscles  being  dialed,  the  edge  of  the 
quadratus  lumborum  was  exposed.  Probatory  puncture  in  the  bottom  of  the  wound 
had  to  be  done  five  times  before  pus  was  found  high  up  close  to  tlie  edge  of  the  twelftli 
rib,  beneath  the  quadratus  muscle.  This  was  drawn  aside,  and  the  cavity  was  opened 
by  Hilton-Eoser's  method.  About  au  ounce  and  a  half  of  odorless  pus  escaped,  and 
digital  exploration  showed  that  it  had  been  contained  in  a  small,  smooth-walled  cavity. 
Drainage  and  antiseptic  dressings  being  applied,  the  wound  was  irrigated  and  dressed, 
daily  ;  later  on,  at  longer  intervals.     The  patient  was  discharged  cured,  September  6th. 

i.  Pyonephrosis,  Renal  Abscess,  and  Calculous  Kidney. — As  an  exhaust- 
ive study  of  the  pathology  and  diagnostics  of  the  yarious  forms  of  suppu- 
rating kidney  would  far  transcend  the  limits  of  this  work,  it  must  he  sutfi- 
cient  to  review  the  conditions  requiring  surgical  interference. 

Whenever  cicatricial  contraction,  of  pressure  from  Avithout,  or  the 
impaction  of  concretions  within  a  ureter  impedes  or  prevents  the  free  exit 
of  the  secretions  of  a  normal  or  diseased  kidney,  dilatation  of  the  pelvis,  or 
in  the  later  stages  of  the  whole  organ,  must  follow.  A  tumor  will  then 
make  its  appearance  in  the  lumhar  region,  the  contents  of  which  may  vary 
in  character.  If  a  suppurative  nephrosis  be  present,  pus  will  be  found 
intermixed  with  urinary  elements,  which  will  be  more  or  less  in  propor- 
tion with  the  amount  of  glandular  tissue  still  performing  its  physiological 
function.  The  longer  the  retention  persists,  the  more  of  the  secreting  ele- 
ments will  perish,  and  finally  the  kidney  will  represent  a  pus-bag  contained 
within  the  fibrous  capsule  of  the  organ.  If  the  causative  factor  be  the  pres- 
ence of  calculi,  these  will  be  found  floating  in  the  retained  fluids. 

Impediments  to  the  exit  of  urine  from  a  normal  kidney  will  be  charac- 
terized by  accumulations  lacking  purulent  elements.  When  all  the  secret- 
ing tissue  has  perished,  a  simple  hydroneplirosis  will  be  established. 

The  presence  of  calculi  in  the  pelvis  and  calyces  of  the  kidney  will 
generally  produce  very  distressing  symptoms,  such  as  local  pain,  hsematuria, 
and  pyuria,  with  fever  and  emaciation,  though  the  pertinent  ureter  may  be 
perfectly  pervious. 

Finally,  discrete  pyogenic  or  tubercular  abscesses  of  the  glandular  kid- 
ney-tissue occur,  causing  all  the  signs  of  a  deep-seated  abscess,  w^hich  may 
require  operative  interference. 

The  diagnosis  must  be  based  on  the  subjective  symptom  of  pain  and 
objective  signs  characteristic  of  the  various  forms  of  kidney  trouble,  as 
fever,  pyuria,  haematuria,  the  presence  of  a  painful  tumor,  and  of  serum  or 
pus  withdrawn  by  the  aid  of  the  aspirating  needle. 

{a)  Nephrotomy. — The  incision  of  the  kidney  for  the  purpose  of  the 
evacuation  of  retained  serum,  pus,  and  calculi,  is  a  safe  operation  often 
possessing  the  dignity  of  a  life-saving  procedure.  It  is  performed  as 
follows  : 

Note. — Aspiration  of  the  diseased  kidney  should  always  be  looked  upon  as  a  diagnostic  and 
not  a  curative  expedient.  The  complete  exhaustion  of  the  purulent  contents  of  a  kidney  pre- 
ceding nephrotomy  may  be  the  source  of  serious  embarrassment,  as  it  is  much  more  difficult  to 
find  an  emptj-,  hence  collapsed  cavity,  than  one  well  distended  by  pus  or  serum. 


280  RULES  OF  ASEPTIC   AND  ANTISEPTIC  SURGERY. 

The  anaesthetized  patient  is  brought  into  Lamjc's  jmsition,  which  can 
not  be  too  warmly  recommended  for  its  eminent  advantages.  (See  Fig.  184, 
page  277.)  Contrary  to  former  usage,  the  patient  is  put  with  the  belly  on 
a  tirm  roll  in  tlie  semi-prone  position,  so  as  to  have  the  diseased  side  not 
uppermost,  but  occupying  the  lowest  level  near  the  edge  of  the  table.  The 
kidney  will  be  pushed  well  up  into  the  loin  by  the  pressure  of  the  subjacent 
roll,  and  will  be  rendered  more  accessible.  Finally,  it  will  be  held  without 
further  external  aids  within  easy  reach.  The  patient's  body  being  well 
protected  in  the  usual  manner,  a  transversely  oblique  incision,  commencing 
two  inches  from  the  spine,  and  carried  midway  between  the  crest  of  the 
ilium  and  the  costal  margin,  is  gradually  laid  through  skin,  fascia,  and 
muscles,  until  the  fascia  containing  the  circumrenal  fat  is  exposed.  With 
this  incision  extended  far  enough  outward,  ample  space  can  be  made  for  the 
removal  of  the  kidney,  should  this  become  necessary,  and  injury  to  the  pleura 
(in  the  absence  of  the  twelfth  rib)  need  not  be  feared.  After  the  fatty 
capsule  is  incised,  masses  of  loose  fat  will  be  seen  bulging  into  the  Avound, 
which  must  be  held  aside  by  sharp  and  later  by  large,  blunt  retractors  (see 
Figs.  17  and  19,  page  40).  A  second  fibrous  septum,  interposed  between  the 
superficial  and  deep  portions  of  the  circumrenal  fat,  will  then  be  encount- 
ered. When  this  is  divided,  the  posterior  and  distal  aspect  of  the  kidney 
will  come  in  view.  The  question  will  arise  now  whether  the  pelvis  or  the 
parenchymatous  portion  of  the  kidney  should  be  incised.  As  it  has  been 
observed  that  wounds  of  the  pelvis  do  not  heal  as  promptly  as  those  made 
through  the  renal  parenchyma,  the  incision  should  be  made  through  the 
latter,  unless  it  be  found  that  a  large  stone  is  occupying  the  pelvis.  A 
thermo-cautery  knife  completes  the  incision,  which  need  not  be  larger  than 
sufficient  to  admit  the  index-finger,  with  which  the  interior  of  the  cavity  is 
explored  after  most  of  the  liquid  contents  have  escaped.  If  no  calculi  are 
found,  a  stout  drainage-tube  is  inserted  and  brought  out  through  the  wound. 
If  stones  are  present,  they  are  extracted  by  means  of  force])s,  the  scoop,  or 
the  hooks  used  by  Lange.  Preceding  this,  further  dilatation  of  the  renal 
incision  may  be  required  to  gain  room  for  the  difficult  process  of  extracting 
irregularly  angular  stones.  This  completed,  tlie  drainage-tube  is  inserted, 
and  the  cavity  is  flushed  with  Thiersch's  solution.  The  external  wound  is 
lightly  filled  with  iodoform  gauze  and  inclosed  in  an  ample  dry  dressing. 
The  drainage-tube  is  to  be  brought  out  through  a  central  slit  in  the  outer 
dressings,  and  is  connected  with  a  longer  tube  carried  under  the  })atient's 
bed,  where  its  end  rests  in  a  suitable  vessel  containing  a  few  ounces  of  car- 
bolic lotion.  Thus  the  necessity  for  a  frequent  change  of  dressings  will  be 
avoided,  should  much  urine  escape  tlirough  the  Avound.  As  soon  as  the 
quantity  of  urine  thus  voided  becomes  small,  the  rubber  tube  attachment 
can  be  left  off.  The  dressings  are  to  be  changed  every  second  or  third 
day  ;  the  tube  is  to  be  retained  for  a  very  long  time.  The  tendency  to  the 
formation  of  a  permanent  fistula  is  strong  in  these  cases,  except  where  cal- 
culi were  extracted  from  an  otherwise  normal  organ.  But,  with  a  scantily 
dischariring  fistula,  life  mav  be  verv  tolerable  indeed. 


DIAGNOSIS  AND  TREATMENT   OF  PHLEGMON.  281 

Nephrotomy  was  performed  by  the  author  eleven  times,  with  two  deaths.  In 
seven  cases  tuberculous  pyonephrosis  necessitated  the  operation,  w^liich  gave  the 
patients  eminent  relief,  freeing  them  from  the  presence  of  large  and  distressing  accu- 
mulations of  pus  in  the  pelvis  of  the  kidney.  Once  the  kidney  was  incised  for  an 
enormous  hydronephrosis.  In  June,  1890,  four  years  after  the  operation,  the  patient 
was  still  wearing  a  cannula  in  a  scantily  discharging  sinus.  Of  the  two  fatal  cases 
nephrotomy  v/as  done  in  one  for  calculous  kidney,  in  which  perforation  into  the 
pleura  and  hence  into  a  bronchus  had  taken  place.  Both  the  thoracic  cavity  and  the 
kidney  were  incised,  but  the  patient  died  of  a  septic  pneumonia  four  days  after  the 
operation.  The  other  case  concerned  a  man  whose  left  kidney  had  been  extirpated 
for  the  cure  of  a  urinary  fistula  remaining  after  nephrotomy  done  for  pyonephrosis 
due  to  cicatricial  obstruction  of  the  corresponding  ureter.  One  month  after  the  heal- 
ing of  the  nephrectomy  wound,  renal  suppression  took  place  on  the  right  side.  The 
patient  was  admitted  to  Mount  Sinai  Hospital  in  a  urtemic  condition.  Though  nephroto- 
my was  promptly  performed,  the  kidney  did  not  recover  its  functional  capacity,  and  the 
man  died  within  twelve  hours  after  the  operation.    (See  case  of  Moses  Oohn,  page  283.) 

{h)  Xeplirectomij. — When  a  kidney  has  become  totally  disorganized 
through  suppuration,  or  has  lost  its  functional  ca2:»acity  in  consequence  of 
the  atrophy  of  the  secreting  tissues,  as,  for  instance,  in  liydrouephrosis  ;  or, 
finally,  where  obliteration  of  a  ureter  has  brought  about  an  incurable  uri- 
nary fistula  of  the  kidney,  extirpation  of  this  organ  may  come  in  question. 
Before  proceeding  to  remove  a  seemingly  useless  or  disorganized  kidney  it 
is  very  desirable  to  ascertain  whether  another  kidney  be  jDresent  or  not. 
All  the  methods  of  examination  hitherto  proposed  for  the  establishment  of 
the  presence  of  two  kidneys,  and  the  diagnostication  of  their  condition  by 
the  catheterism  of  the  ureters,  have  been  found  unsatisfactory  and  unreli- 
able. Hence,  if  there  is  any  doubt  of  the  presence  of  two  kidneys  which  can 
not  be  eliminated  by  the  ordinary  means  of  physical  examination,  nothing 
remains  but  an  exploration  through  either  an  abdominal  or  a  lumbar 
section.  Lumbar  nephrectomy  is  performed  as  follows  :  Without  regard  to 
a  pre-existing  sinus,  the  external  incision  is  made  as  described  in  the  chapter 
on  nephrotomy.  When  the  surface  of  the  kidney  is  reached,  the  organ  is 
separated  from  the  surrounding  fatty  tissue  by  blunt  dissection,  most  con- 
veniently done  by  the  tip  of  the  index-finger.  Occasionally  a  more  resist- 
ing band  will  have  to  be  severed  by  a  touch  of  the  knife  or  scissors.  As 
soon  as  the  kidney  is  well  separated,  it  can  be  brought  out  of  its  niche  by 
traction,  unless  its  size  is  very  large,  when  subsidiary  incisions  will  have  to 
be  added.  Even  then  occasionally  manoeuvres  will  have  to  be  made  resem- 
bling the  development  of  the  infantile  head  from  the  vulva — that  is,  the 
kidney  will  have  to  be  tilted  and  brought  out  with  its  end  on.  This 
being  done,  the  vessels  and  ureter  are  separated  and  tied  each  by  itself 
with  stout  catgtit,  and  the  pedicle  is  cut  oif  at  a  safe  distance  from  the 
ligatures,  which  are  also  cut  off  short.  Tlie  wound  is  well  irrigated,  and, 
if  any  oozing  be  present,  is  packed  with  iodoform  gauze.  Secondary 
sutures  maybe  then  employed,  which  can  be  closed  after  the  removal  of  the 
packing  on  the  third  day.  A  drainage-tube  will  be  needed  after  the  suture 
is  completed,  to  prevent  retention.     If  no  considerable  oozing  prevail,  the 


2b2  RULES  OF   ASEPTIC   AND  ANTISEPTIC  SURGERY. 

wound  can  be  at  once  sutured,  after  a  good-sized  drainage-tube  was  slipped 
into  the  bottom  of  tlie  cavity.  In  separating  the  kidney,  the  i>eritonfeum 
mav  be  accidentally  injured.  In  this  case  the  rent  ought  to  be  at  once 
closed  by  suture,  if  possible  ;  if  not,  a  strip  of  iodoform  gauze  ought  to  be 
stuffed  temporarily  into  the  rent,  until  the  kidney  is  removed,  when  the 
peritonaeum  can  be  more  conveniently  stitched. 

The  after-treatment  by  packing  and  secondary  suture  will  be  the  safer 
procedure  in  all  those  cases  where  unavoidable  contamination  of  the  deep 
cavity  bv  pus,  escaping  either  from  a  pre-existing  sinus  or  in  consequence 
of  the  rupture  of  the  wall  of  an  intrarenal  abscess,  had  taken  place. 

Though  not  commonly,  yet  it  occurs  that,  in  consequence  of  long-contin- 
ued inflammation,  the  fibrous  capsule  has  entered  into  such  an  intimate  and 
firm  union  with  the  condensed  and  shrunken  circumrenal  fat,  that  the  enu- 
cleation of  the  kidney  becomes  a  very  difficult  and  hazardous  undertaking. 
In  these  cases  the  proper  mode  of  procedure  is  this  :  After  having  exposed 
the  kidney,  the  fibrous  cai)sule  is  split  open  along  the  outer  edge  of  the 
organ,  which  now  can  be  readily  stripped  out  of  its  fibrous  coat.  On  devel- 
oping the  gland,  the  rather  stout  pedicle  is  secured  in  an  elastic  ligature, 
and  cut  off.  If  need  be,  the  section  of  the  pedicle  can  be  carried  through 
the  renal  tissue,  in  order  to  prevent  slipping  of  the  ligature.  The  wound  is 
drained  and  packed,  and  tlie  ligature  is  brought  out  near  the  inner  angle 
of  the  wound.  The  sloughing  pedicle  will  come  away  in  about  ten  days, 
when  the  size  of  the  wound  can  be  reduced  by  secondary  suture. 

Case  I. — Solumon  Posner.  aged  thirty-seven,  an  emaciated,  anxious-looking  tailor, 
had  been  suffering  from  cystitis  since  January,  18S8.  Two  years  previous  to  this  had 
had  an  attack  of  renal  colic  of  the  left  side.  Frequent  and  very  painful  urination  with 
blood  and  pus,  no  renal  elements,  but  a  trace  of  albumen  in  filtered  urine.  Intermit- 
tent attacks  of  high  fever.  No  pain  on  pressure  in  the  loins.  Koteinber  2^  1888. — 
Temperature  102""  Fahr.  Suprapubic  cystotomy  at  Mount  Sinai  Hospital.  The 
interior  of  much  congested  bladder-wall  studded  with  miliary  tubercle,  and  bleeding 
at  the  slightest  touch.  T-tube  inserted,  outer  wound  packed.  Two  hours  after  opera- 
tion, profuse  capillary  haemorrhage  from  the  bladder  was  observed.  It  was  checked 
by  tamponade  of  the  viscus  with  iodoform  gauze.  The  fever  continuins,  and  a  jjainful 
tumor  having  developed  in  the  left  loin,  this  was  aspirated  December  14th,  when  muco- 
pus  was  withdrawn,  December  21st. — By  nepthrotomy  done  in  chloroform  anaesthesia 
a  large  quantity  of  pus  was  evacnated.  A  drainage-tube  was  inserted  into  the  pelvis 
of  the  kidney,  from  wliich  no  urine  ever  escaped.  DecenJier  25th. — Forty  ounces  of 
urine  were  collected  from  the  bladder.  The  fever  subsided  somewhat,  but  there  was 
an  exacerbation  every  evening.  As  there  was  good  reason  to  suppose  that  the  other 
kidney  was  fairly  healthy,  and  in  view  of  the  fact  that  the  patient's  strength  was 
being  steadily  sapped  by  the  nightly  fever,  nephrectomy  was  performed  January  25, 
1889.  The  very  large  kidney  was  exposed  by  an  ample  T-shaped  incision.  Its  sepa- 
ration was  very  difficult,  and  though  the  eleventh  and  twelfth  ribs  were  resected,  lack 
of  space  led  to  the  injury  of  tlie  peritonaeum.  After  the  development,  deligation,  and 
removal  of  the  organ,  the  peritoneal  rent  was  closed  by  suture.  Wound  packed,  no 
external  suture.  The  pelvis  of  the  kidney  was  lined  with  closely  adlierent  cheesy 
Miasses ;  the  cortical  and  pyramidal  substance  stndded  with  a  large  number  of  smaller 
and  larger  caseous  abscesses.     The  rather  collapsed  patient  rallied  well,  and  the  tem- 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  283 

perature  fell  off  and  did  not  range  after  this  above  100°  Fabr.  January  27th. — 
Passed  tbirty-six  ounces  of  urine  in  twenty-four  hours.  Up  to  February  4tb  every- 
tbing  went  well,  so  that  the  patient  sat  up  on  the  afternoon  of  that  day,  and  retired 
aftcT  a  bearty  sup|)er  at  8  p.  m.  The  evening  observation  gave  temperature  100^  Fabr. ; 
pulse,  90;  urine,  thirty-six  ounces.  At  11  p.  m.  suddenly  stertorous  breathing  set  in, 
the  pulse  ran  up  to  120,  the  patient  was  comatose,  with  insensible  conjunctiva,  and  a 
deeply  flushed  face.  There  bad  been  no  vomiting  or  headache.  Urine  was  still  seen 
dripping  out  of  the  catheter  placed  in  the  patient's  bladder.  Tbe  wound  was  exam- 
ined and  found  in  good  order.  Death  ensued  at  5.15  a.  m.  No  autopsy  could  be  se- 
cured. As  tbe  assumption  of  urgemia  was  hardly  justified,  it  is  probable  that  a  throm- 
bus found  in  tbe  stump  of  the  renal  vein  became  detached  and  gave  rise  to  pulmonary 
embolism. 

Case  II. — Rosaly  Cronn,  bousewife.  aged  fifty-six,  began  in  1883  to  have  rigors, 
paroxysmal  pains  in  the  left  hypogastric  region  with  painful  and  frequent  voiding  of 
turbid  urine.  These  attacks  recurred  every  few  months  for  four  years  till  1887,  when 
a  tumor  made  its  appearance.  August,  1888. — A  large  quantity  of  pus  was  evacuated 
by  an  incision  made  in  tbe  left  loin.  General  condition  was  soraewbat  improved,  but 
a  discharging  sinus  remained  behind.  October  8,  1889. — On  ber  admission  to  Mount 
Sinai  Hospital  a  dense  resisting  and  painful  tumor  could  be  felt  in  the  left  loin.  A 
probe  introduced  into  tbe  existing  lumbar  sinus  led  down  toward  this  swelling.  The 
woman  was  poorly  nourisbed ;  her  urine  contained  pus,  blood,  and  a  little  albumen, 
but  no  casts.  October  SI,  1889. — Neplirectomy .  The  sinus  led  into  tbe  small,  shrunk- 
en and  lobulated  kidney.  Tbe  swelling  felt  before  tbe  operation  was  accounted  for  by 
a  dense  cicatricial  deposit  in  which  tbe  organ  lay  imbedded,  A  number  of  calculi 
were  struck  by  a  needle  thrust  througb  the  kidney,  wliicb  was  found  converted 
into  a  cicatricial  bag.  The  fibrous  capsule  was  divided,  and  the  organ  was  stripped 
out  of  it.  Tbe  very  sbort  pedicle  was  ligatured  in  mass  and  tbe  kidney  was  cut 
away.  A  cylindrical  calculus  was  found  caught  in  tbe  ligature,  but  was  easily  with- 
drawn from  tbe  stump.  The  peritonaeum  was  accidentally  rent  during  the  first 
attempts  to  separate  tbe  organ.  The  rent  was  stopped  up  with  a  strip  of  iodoform 
gauze  which  was  left  in  situ  ti'l  the  dressings  were  changed  on  tbe  fourth  day.  Octo- 
ber 23d. — Tbe  temperature  had  not  risen  above  100°  Fabr.  Patient  had  passed  twen- 
ty-four and  a  half  ounces  of  urine  in  twenty-four  hours.  It  contained  granular  hyaline 
and  blood  casts.  General  condition  was  good.  October  24th. — Urine  forty-two  ounces ; 
temperature  normal.  From  October  28tb  on  the  casts  disappeared  from  tbe  urine,  but 
slight  quantities  of  pus  were  still  observed.  November  16th. — The  ligatures  and 
stump  came  away.  Secondary  suture  had  to  be  done  twice  to  hasten  tbe  closure  of 
the  large  wound.     Discharged  cured,  December  15,  1889. 

Cask  III.— Moses  Cobn,  tailor,  aged  forty-two,  had  had  within  tbe  last  four  years  a 
number  of  severe  attacks  of  renal  colic,  accompanied  by  rigors  and  turbid  ui-ine. 
Three  weeks  before  his  admission  to  Mount  Sinai  Hospital  another  attack  set  in  with 
vomiting,  repeated  chills,  and  severe  pain  in  tbe  left  loin.  The  fever  continued  till 
his  admission,  November  12,  1889,  when  the  temperature  was  101°,  the  iirine  abso- 
lutehi  normal,  but  in  tbe  left  loin  a  painful  tumor  was  felt,  which  could  be  v/ell  sepa- 
rated from  the  somewhat  enlarged  spleen.  November  Hth. — By  an  exploratoi-y 
puncture  sanguino-purulent,  urinous  smelling  serum  was  withdrawn.  The  kidney 
was  exposed,  and  was  found  considerably  distended.  From  an  incision  about  twelve 
ounces  of  matter  were  evacuated.  The  kidney  was  drained  so  as  to  catch  the  dis- 
charges in  a  vessel  placed  below  tbe  bed.  The  patient's  condition  was  immediately 
improved  in  every  way,  but  the  same  quantity  of  urine  continued  to  escape  from  tbe 
drainage-tube  as  from  tbe  bladder,  averaging  about  twenty  ounces  from  every  side. 
38 


284  RULES  OF  ASEPTIC   AND  ANTISEPTIC  SURGERY. 

Apparently  the  left  ureter  was  completely  blocked,  and,  as  there  was  no  improvement 
noticed  until  December  14th,  it  was  decided  then  to  explore  the  left  ureter.  A 
slender  elastic  bougie  was  passed  into  the  urett-r,  and  was  arrested  at  a  distance  of 
five  inches,  the  channel  aiipeariug  to  be  impassable.  Thereupon  the  kidney  was  re- 
moved, though  it  was  apparently  healtliy.  December  15th. — Patient  did  well;  passed 
twenty-five  ounces  of  urine  in  twenty-four  hours;  temperature  normal.  December 
20th. — Passed  forty-six  ounces  of  urine  containing  traces  of  albumen  and  a  little 
pus.  February  ^th. — Secondary  suture.  February  16th. — Patient  was  discharged 
cured  and  in  excellent  health.  March  13th. — lie  was  readmitted  with  obstructive 
symptoms  of  the  hitherto  unaffected  right  kidney,  which,  however,  yielded  to  treat- 
ment. Discharged  at  his  own  request,  March  21st.  March  SJ^th. — He  was  readmit- 
ted with  absolute  renal  sup[)ression,  which  was  not  influenced  by  medication,  where- 
fore nephrotomy  was  performed,  March  28th,  on  the  uraemic  patient.  The  evacuation, 
of  much  urinous  pus  was  of  no  avail ;  the  intoxication  was  too  far  gone,  and  led,  in 
spite  of  diligent  attention,  to  his  death,  March  31st.  A  number  of  small  renal  calculi 
were  extracted,  and  proved  the  mechanical  nature  of  the  obstruction  of  the  ureter. 
The  autopsy  revealed  softened  and  nmch  swollen  parenchyma  of  unusually  liglit  color, 
the  ureter  obstructed  by  calculous  detritus. 

Case  IV.— Oscar  llettler,  barkeeper,  aged  twenty-seven,  has  suffered  from  acute 
attacks  of  pain  in  the  right  lumbar  region  since  three  years,  the  pain  radiating  to  the 
glans  penis.  Ten  days  before  admission  to  the  German  Hospital,  fever  set  in  with  much 
sweating.  February  5,  1889. — On  admission,  marked  anaemia,  a  movable  tumor  in  the 
right  loin  and  urine  containing  much  pus.  February  11th. — Dr.  W.  Meyer,  then  on 
duty,  evacuated  a  considerable  quantity  of  pus  by  nephrotomy.  February  13th. — The 
author  took  charge  of  the  patient.  In  spite  of  free  drainage  he  continued  to  fail. 
March  8tli. —  High  and  constant  fever  set  in,  the  temperature  rising  to  above  103° 
Fahr.,  and  a  careful  physical  examination  did  not  reveal  any  complication  by  involve- 
ment of  other  organs.  March  IJ^th. — Nephrectomy  was  done.  It  was  an  easy,  short, 
and  comparatively  bloodless  operation,  from  which  the  patient  rallied  well.  During 
the  first  twenty-four  hours  thirty  ounces  of  urine  were  voided.  The  high  tempera- 
tures continued  unchanged.  March  23<l. — Patient  passed  twenty  ounces  of  urine. 
Temperature  still  103°  Fahr.,  and  remained  high  until  the  patient's  death,  which  oc- 
curred April  11,  1890.  The  excised  kidney  contained  a  number  of  smaller  and  larger 
tuberculous  foci,  most  of  them  not  communicating  with  the  pelvis.  Atitopsy  revealed 
almost  general  miliary  tuberculosis.  The  lungs,  left  kidney,  liver,  and  spleen  were 
studded  with  innumerable  spots  of  miliary  tubercle  of  recent  origin.  Apparently 
their  development  caused  the  patient's  death.  Repeated  careful  examinations  had 
failed  to  reveal  the  slightest  physical  signs  of  the  presence  of  this  extensive  process. 

k.  Anal  Abscess.  Fistula  in  Ano. — The  anus,  the  final  strait  tlirongh 
which  all  excrementitious  matter  must  pass,  is  subject  to  a  great  number  of 
traumatisms  from  within  and  without.  Foreign  bodies,  such  as  pits  and 
kernels,  chicken  and  fisli  bones,  are  frequently  caught  by  and  imbedded  in 
the  mucous  lining  of  the  sphincter  muscle.  Tlie  rough  introduction  of 
syringe-points  for  the  application  of  enemata,  scratching  and  manipulation 
of  itching  and  bleeding  piles,  the  surgeon's  digital  exploration,  sodomy, 
and  the  forcible  expulsion  of  massive  faeces,  lead  to  superficial  injuries  of  the 
mucous  membrane  and  outer  skin  of  the  anal  region.  Persons  whose  hands, 
and  faces  are  habitually  unclean  do  not  scruple  much  about  the  untidy  con- 
dition of  their  breech.     And  tlie  faeces  of  even  the  most  cleanly  swarm  witli 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  285 

bacteria.    In  view  of  these  facts,  the  frequency  of  ulcerative  and  suppurative 
affections  of  tlie  anal  region  must  appear  very  natural. 

Anal  adscesses  are  generally  located  in  the  ischio-rectal  fossa.  This  is 
the  space  limited  by  the  rectum  on  the  median  side,  the  tuberosity  of  the 
ischium  externally,  the  levator  ani  muscle  above,  the  superficial  perineal 
fascia  below.  It  is  very  rare  to  meet  with  a  periproctitic  abscess  situated 
above  the  levator  ani.  If  such  is  the  case,  we  have  to  deal  with  graver 
affections  involving  the  pelvic  organs,  or  with  abscess  from  ulceration  due 
to  stercoral  impaction  caused  by  cancerous  rectal  stricture. 

Case. — Mary  Steiger,  aged  fifty-nine.  Far-gone  cancer  of  rectum.  Stenosis  very 
tight,  causing  great  difficulty  at  defecation.  A  profuse  purulent  discliarge  from  tlie 
anus  indicated  the  presence  of  ulcers  or  an  abscess  above  the  stricture.  Exploration 
of  the  rectum  above  the  cancer  was  absolutely  impossible.  High  temperatures  were 
noted.  August  13, 1885. — Anterior  colotomy  in  the  German  Hospital.  No  diminution 
of  fever  after  the  operation.  August  16th. — Wound  healed  by  the  first  intention. 
August  17th. — Patient  delirious.  Discharge  from  anus  very  profuse.  August  18th. — 
Patient  died  with  symptoms  of  septicemia.  Post  mortem  revealed  firm  union  of 
colotomy  wound  throughout  and  a  normal  peritoneal  cavity.  In  the  sacral  excavation, 
just  above  the  massive  ulcerated  cancer,  a  very  large  fetid  abscess  was  found. 

The  presence  of  anal  abscess  is  the  source  of  intense  suffering  to  the 
patient,  and  ascertaining  of  its  precise  location  by  the  surgeon  is  generally 
not  very  difficult.  By  digital  examination  of  the  rectum  a  resistant,  hard, 
or  sometimes  fluctuating  swelling  can  be  felt  protruding  laterally  into  the 
gut.  Early  incision  is  very  urgently  indicated,  as  upon  it  may  depend  the 
avoidance  of  the  formation  of  fistula,  or  of  a  dissecting  or  "horse-shoe 
abscess,"  which  may  detach  almost  the  entire  lower  gut  from  the  adjacent 
connective  tissue.  This  latter  form  of  abscess  is  especially  to  be  feared,  as 
its  healing  is  extremely  difficult.  But,  where  fluctuation  is  absent,  success- 
ful evacuation  of  a  deep-seated  periproctitic  abscess  is  no  easy  matter. 

After  a  purge  and  enema,  the  patient  should  be  ansesthetized  and 
brought  into  Bozeman's  or  the  lithotomy  position.  (See  Fig.  122,  page  167.) 
A  sponge  tied  to  a  piece  of  stout  silk  is  pushed  well  into  the  rectum,  and 
the  lower  end  of  the  gut  and  the  anal  region  are  flushed  with  corrosive-sub- 
limate lotion.  Then  the  index-finger  is  introduced  and  placed  against  the 
swollen  side  for  fixation.  A  stout  exploring  needle  is  thrust  through  the 
skin  into  the  swelling  repeatedly  from  without  until  it  strikes  the  suppurat- 
ing focus.  It  is  left  in  situ  for  a  guide,  and  an  ample  incision  is  gradually 
extended  until  the  abscess  is  freely  opened.  The  wound  should  have  the 
shape  of  a  funnel,  its  apex  being  in  the  abscess.  This  will  secure  natural 
drainage.  The  wound  is  loosely  packed  with  iodoformed  gauze,  and  the 
anus  is  inclosed  in  a  moist  dressing,  which  should  be  renewed  every  day. 
Daily  irrigation,  or  in  very  irritable  patients  a  sitz  bath,  will  have  to  main- 
tain cleanliness. 

In  cases  where  extensive  detachment  of  the  rectum  or  perforation  into 
the  gut  has  taken  place,  simple  incision  will  be  insufficient,  and  division  of 
the  intervening  bridge  will  be  necessary. 


286  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

By  spontaneous  evacuation  outward,  external  incomplete  fistula  will  be 
established.  8ome  of  these  cases  can  still  be  cured  by  a  free  bloody  dilata- 
tion of  their  orifice,  and  a  careful  antiseptic  treatment  as  above  indicated. 
But  most  of  them  are  complete  fisttilcB,  the  inner  openings  of  which  can  not 
be  found  on  account  of  their  minuteness. 

Cases  of  incomplete  internal  and  of  complete  tistuhi  should  be  cut. 

In  incomplete  inner  fistula  a  Sims'  vaginal  speculum  is  used  for  exposing 
the  entrance  to  the  sinus.  A  bent  probe  and  alongside  of  this  a  bent 
grooved  director  is  introduced  into  it,  and  is  pushed  well  outward  toward 
the  skin,  which  is  incised  over  the  point  of  the  instrument.  After  this  the 
intervening  bridge  is  divided. 

Complete  anal  fistula,  especially  where  several  sinuses  exist,  should 
always  be  carefully  explored  before  the  incision  is  made,  as  otherwise 
pockets  and  branching  sinuses  may  be  overlooked.  A  silver  probe  should 
be  introduced  into  each  sinus  and  left  in  situ  until  its  turn  for  cutting 
should  come.  A  grooved  director  is  carried  into  the  gut  along  one  of  the 
probes,  is  caught  up  by  the  tip  of  the  left  index-finger,  and  turned  out  of 
the  anus.  The  bridge  of  tissue  taken  up  by  it  is  then  divided.  The  edges 
of  the  cut  are  well  drawn  apart  by  four-pronged  sharp  hooks,  in  order  to 
facilitate  securing  and  tying  of  spurting  vessels.  The  next  sinus  is  taken 
up  after  the  first,  and  every  nook  and  recess  is  carefully  examined  and  split 
open  until  natural  drainage  is  secured  everywhere.  Free  irrigation  of  the 
wound  should  be  employed  during  the  whole  process.  When  hemorrhage 
is  properly  attended  to,  all  the  old  granulations  should  be  forcibly  scraped 
away  with  the  sharp  spoon,  and  the  wound  should  be  packed  with  narrow 
strij)s  of  iodoformed  gauze.  After  this  the  sponge  is  withdrawn  from  the 
rectum,  and  a  moist  dressing  is  applied  and  held  in  place  by  a  T-bandage. 
(Fig.  126,  page  170.) 

Note — Wlien  the  internal  oiifice  can  not  be  found,  or  a  burrow  extends  upward  beyond 
it,  the  grooved  director  should  be  inserted  as  high  up  as  the  cavity  or  sinus  permits,  and  thence 
should  be  thrust  through  the  mucous  membrane  into  the  gut. 

The  length  of  time  required  for  the  cure  of  fistula  in  ano  will  depend 
on  the  extent  and  form  of  the  wound  made  by  the  surgeon.  In  simple 
cases  a  fortnight  or  three  weeks  will  suffice  ;  complicated  ones  may  need 
months.  In  favorable  cases,  that  is,  where  the  fistula  is  straight  and  single, 
cu7'e  can  be  very  much  hastened  by  excision  and  suture  of  the  entire  fistu- 
lous track.  The  restitution  of  the  parts  to  their  normal  condition  will  at 
the  same  time  insure  against  incontinence.  The  callous  lining  of  the  sinus 
is  carefully  excised  with  forceps  and  curved  scissors,  and  the  remaining 
wound  is  united  by  several  tiers  of  buried  catgut  sutures,  the  ends  of  which 
should  be  clipped  off  short.  The  uppermost  tier  of  sutures  should  not 
inclose  the  mucous  membrane,  but  the  curved  needle  should  be  introduced 
close  to  its  edge  on  one  side,  and  brought  out  in  the  same  manner  on  the 
other  side.  Thus  inversion  of  the  mucous  lining  will  be  avoided,  and  the 
stitches,  being  buried  under  the  overlapping  edges  of  the  mucous  mem- 
brane, will  be  protected  from  infection  by  intestinal  contents.     The  exter- 


DIAGNOSIS  AND  TEEATMENT  OF  PHLEGMON. 


2S7 


Fig.  188.— Operation  of  fistula  in  ano.  Grooved  director 
passed  tlirough  f  stula  and  brought  out  of  the  anus, 
from  which  is  seen  depending  a  thread  liolding  sponge 
pushed  well  up  the  rectum.     (Simon  Schulhof's  case.) 


nal,  that  is,  cutaneous,  part  of  the  wound  can  be  closed  by  silver-wire  stitches. 
Free  irrigation  of  the  wound  during  the  entire  time  of  the  operation  is  indis- 
pensable to  preserve  asejisis. 
Iodoform  is  dusted  over  and 
rubbed  into  the  line  of  union, 
and  the  anus  is  inclosed  in  a 
moist  dressing. 

Case. — Simon  SchulLof,  labor- 
er, aged  forty-tliree  and  a  half,  re- 
ceived, during  the  Austro-Prus- 
sian  war  of  1866,  a  bayonet  wound 
near  the  anus.  Suppuration  and 
the  formation  of  fistula  followed, 
and  resisted  three  operations  which 
had  been  performed  since  that 
time.  February  5,  i557.— Under 
ether,  the  tistula  was  slit  up  at 
the  German  Hospital.  Its  exter- 
nal orifice  was  nearly  two  inches 
from  the  anal  margin;  the  inter- 
nal one,  one  inch  and  a  half  up 
the  rectum.  The  direction  of  the 
track  was  straight,  and  no  lateral 
sinuses  were  present.  The  en- 
tire cicatricial  lining  of  the  fistula  was  excised  with  forceps  and  curved  scissors,  and 
the  internal  defect  was  united  with  three  tiers  of  fine  catgut  sutures.     The  external 

wound  was  brought  together  with  two  silver- 
wire  stitciies.  Into  the  outer  angle  of  the 
skin-wound  a  short  piece  of  slender  rubber 
drainage-tube  was  placed.  A  pledget  of  iodo- 
forraed  gauze  was  placed  into  the  anus,  and 
the  wound  was  dressed  with  gauze  and  a  T- 
bandage.  No  reaction  followed.  In  the  after- 
noon of  February  7th,  four  ounces  of  sweet- 
oil  were  injected  into  the  gut,  and  the  oil- 
soaked  gauze  was  withdrawn  from  the  anus. 
An  hour  after  this  a  large  enema  of  soap- 
water  was  administered,  and  brought  away  a 
liquid  stool.  The  next  morning  a  saline  laxa- 
tive was  given,  and  was  continued  every  day, 
each  stof)l  being  followed  by  irrigation  of 
the  anus  to  free  it  from  excrementitious  mat- 
ter. February  10th.— The  silver  stitches  and 
rubber  tube  were  removed.  The  accompany- 
ing cut  shows  the  condition  of  the  wound  on 
the  tenth  day  after  the  operation.  The  action 
of  the  sphincter  was  perfect.     (Fig.  189.) 

Kegarding  the  management  of  the  first  and  subsequent  evacuation  of 
the  bowels,  the  reader  is  referred  to  the  chapter  on  ha?morrhoids  (page  169). 


**" 

% 

^ 

•;•-■ 

% 

^ 

K 

• 

^  M 

i 

'^--- 

A 

1 

--. .t,: 

Fig.  189. — Eesult  after  excision  and  suture 
of  fistula  in  ano.     (Simon  SchuUiof's  case.) 


288  RULES  OF  ASEPTICS   AND  ANTISEPTIC  SURGERY. 

In  very  extensive  cases  of  fistula  of  long  standing,  where  the  inner 
orifice  is  very  high  up,  say  two  inches  or  more  above  the  anal  opening, 
and  where  avoidance  of  hgemorrhage  is  rendered  imperative  on  account  of 
the  ansemic  condition  of  the  jiatient,  the  elastic  ligature  can  he  successfully 
substituted  for  the  knife.  The  grooved  director  is  carried  through  the 
sinus  into  the  gut  as  usual,  and,  if  possible,  its  point  is  turned  out  of  the 
anus.  Where  tliis  is  impossible,  a  slender,  soft,  silver  probe  is  armed  with 
a  fillet  of  stout  silk,  to  the  end  of  which  a  piece  of  elastic  ligature  or  a 
small-sized  drainage-tube  (the  size  used  on  infants'  feeding-bottles  is  very 
good)  is  firmly  tied.  The  silver  probe  is  next  carried  along  the  grooved 
director  into  the  gut,  its  point  is  caught  up  by  the  tip  of  the  left  index- 
finger,  and  being  bent  upon  itself  is  grasped  with  a  stout  pair  of  dressing- 
forceps  and  withdrawn.  Thus  the  silk  thread  will  be  placed  into  the  sinus, 
and  with  a  seesaw  motion  will  clear  a  way  for  the  elastic  ligature,  which  is 
drawn  through  after  it.  The  ends  of  the  elastic  ligature,  being  firmly  held 
each  by  one  hand,  are  well  drawn  upon,  and  become  tense  and  attenuated. 
Thus  stretched,  they  are  crossed  over  each  other  in  front  of  the  anus,  and 
are  secured  in  this  position  by  a  ligature  of  silk.  As  soon  as  the  rubber  is 
released,  it  crowds  up  against  the  silk  ligature,  and  is  held  securely  in 
place.     Its  ends  are  trimmed  off  short. 

The  elastic  ligature  is  in  every  way  preferable  to  the  silken  one,  as  it 
cuts  tlirough  more  rapidly,  and  does  not  require  retightening. 

Where  the  external  orifice  of  the  fistula  is  not  close  to  the  anal  opening, 
the  intervening  skin  must  be  cut  through  with  the  knife  before  the  tight- 
ening of  the  ligature,  to  avoid  the  intense  pain  due  to  strangulation  of  the 
cutaneous  nerves. 

Incontinence  is  occasionally  produced  by  fistula  operations  requiring 
single  or  multiple  division  of  the  entire  sphincter.  In  these  cases  a  sec- 
ondary pj'octoplasty  offers  fair  chances  of  partial  or  complete  recovery  of 
the  function  of  the  muscle. 

Case. — Barto  Weil,  brewer,  aged  fifty-six,  suffered  from  distressing  incontinence 
of  the  rectum,  caused  by  four  extensive  fistula  operations,  performed  successively  for 
the  horseshoe  variety  of  this  affection.  At  the  last  operation  the  author  applied  two 
elastic  ligatures,  one  of  which  reached  three  inches,  the  other  three  inches  and  a  half 
up  the  rectum.  An  irreguhir  gaping  aperture  remained,  from  which  rectal  mucous 
membrane  protruded  in  a  number  of  folds.  One  granulating  oblong  surface  was  still 
extending  nearly  two  inches  into  the  gut.  May  S8,  1886. — Under  ether,  tlie  entire 
irregular  cicatiix  was  excised,  and  the  remaining  flaps  of  mucous  membrane,  together 
with  the  lower  end  of  the  uncut  rectum,  were  dissected  up  and  drawn  well  down. 
By  a  large  number  of  catgut  stitches  the  cylindrical  shape  of  the  anal  opening  was 
re-established,  and  the  new  anal  ring  was  sewed  to  the  external  skin.  A  triangular 
defect  remaining  on  the  right  of  the  anus  was  covered  by  a  skin-flap  shaped  out  of  a 
shrunken  integumental  caruncle  found  posteriorly.  Two  small  drainage-tubes  wei-e 
placed  well  up  between  rectum  and  ischio-rectal  connective  tissue.  Primary  union 
followed  through  the  greater  extent  of  the  wound,  and  ultimately  continence  was 
fairly  re-established.     The  patient  was  discharged  cured  July  24,  1886. 


ERYSIPELAS  AND  PSEUDO-ERYSIPELAS. 


280 


CHAPTER  VIL 


ERYSIPELAS  AND   PSEUDO-ERYSIPELAS. 


The  rules  of  aseptic  managemeut  described  in  former  chapters  are  the 
best  safeguard  against  the  infection  of  operative  wounds  by  the  specific  coc- 
cus of  erysipelas.  (Fig.  131,  page  183  ;  Plate  II,  Figs.  5  and  6  ;  and  Fig. 
190.)  The  author  has  observed  only  four  cases  of  wound  erysipelas  in  ten 
years  both  of  public  and  private  practice.  In  one  of  these,  in  1879,  ery- 
sipelatous infection  was  transmitted  from  a  case  of  so-called  idiopathic 
erysipelas  of  the  face  to  the  genitals  of  a  woman  in  childbirth  by  the  author's 
hands,  in  spite  of  ordinary  measures  of  cleanliness.  Had  disinfection  been 
applied  after  the  usual 
washing  of  the  hands,  the 
patient  might  have  been 
living  to  this  day. 

The  other  case  of  ery- 
sipelas was  observed  after 
the  first  visit  of  a  new 
member  of  the  house- 
staff  of  Mount  Sinai  Hos- 
pital, at  which  the  dress- 
ing of  a  nearly  healed 
wound  was  changed  by 
the  young  physician  in 
question.  The  case  was 
cured. 

Note. — The  time  of  changes 
in  the  house-staff  of  the  surgical 
wards  of  hospitals  is  generally      gf"  -       ^ 

signalized  by  unexpected  suppu- 
rations.   The  author  has  learned  Ym.  190. 
to  dread  the  loss  of  a  good  and 
well-trained    assistant,    who    is 

occasionally  replaced  by  an  inefBcient,  uncleanly,  and  indolent  personage.  Disaster  can  be 
averted  at  such  times  only  by  increased  vigilance  and  redoubled  diligence  on  the  part  of  the 
visiting  surgeon  in  personally  supervising  the  details  of  the  service. 

The  third  case  was  mentioned  in  the  paragraph  on  perityphlitie  abscess. 

The  last  case  of  erysipelas  within  the  author's  experience  was  that  of  a 
young  woman  suffering  from  caseous  cervical  glands.  For  cosmetic  reasons 
the  glandular  swellings  were  punctured  with  a  narrow  bistoury,  and,  a  small 
curette  being  introduced  into  the  broken-down  center  of  the  gland,  its  case- 
ous contents  were  scraped  out.  The  small  wounds  were  drained  with  cat- 
gut.    Erysipelas,  commencing  from  one  of  the  punctures,  set  in,  but  ended 


-Section  of  erysipelatous  skin  of  head  (700 
diameters).     (Koch.) 


200  RULES  OF   ASEPTIC   AND   ANTISEPTIC  SURGERY. 

in  cure.     Undoubtedly  either  the  bistoury  or,  more  likely,  the  sharp  spoon 
was  the  carrier  of  the  virus. 

There  is  not  one  among  the  many  tojiical  remedies  recommended  by  the 
writers  for  erysipelas  that  is  pre-eminent  in  limiting  or  stopping  the  affec- 
tion. The  author's  local  treatment  consists  in  moist  antiseptic  dressings 
inclosing  the  affected  parts,  with  a  general  supporting  treatment  by  proper 
nourishment  and  stimulants.  The  much-praised  specific  effect  of  the  tinct- 
ure of  iron  is,  to  say  the  least,  very  problematic. 

Note. — Lately  Kraske  has  published  a  series  of  cases  in  which  multiple  scarification  and 
puncture  of  the  affected  parts,  especially  along  the  line  of  the  spread  of  the  disease,  has  led  to 
prompt  cure.  The  little  operation  is  followed  by  the  application  of  a  moist  antiseptic  dressing. 
As  the  principle  of  this  mode  of  therapy  is  rational,  consisting  in  depletion  and  disinfection,  it 
would  deserve  extended  trial. 

An  unmixed  infection  by  the  coccus  of  erysipelas  will  never  cause  ab- 
scesses. Whenever  abscesses  form  with  erysipelas,  we  have  to  deal  with  a 
mixed  infection,  namely,  by  the  coccus  of  erysipelas,  and  by  one  or  another 
of  the  pus-generating  cocci. 

Phlegmon  and  erysipelas  also  represent  a  mixed  form  of  infection,  but 
this  combination  is  rare.  What  is  generally  called  ])1iIogmonotift  erysipelas 
is  commonly  no  erysipelas  at  all.  It  is  a  phlegmon  produced  by  the  pyo- 
genic chain-coccus,  the  spread  of  which  along  the  lymphatics  resembles  that 
of  true  erysipelas. 

Pseudo-erysipelas  is  an  erysipelatoid  skin  affection  of  the  fingers  and 
hand  that  resembles  true  erysipelas  in  most  of  its  morphological  features. 
But  it  presents  this  important  clinical  difference,  that  it  never  is  accompa- 
nied by  fever.  The  affection  is  very  tractable,  as  the  application  of  a  three- 
per-cent  carbolic  lotion  for  a  few  hours  will  generally  consummate  a  cure. 
Its  cause  is  a  specific  coccus  described  by  Rosenbach. 


PART    III. 

TUBERCULOSIS  : 

ITS  ASEPTIC  AXD  A:N^TISEPTI0   TREATMENT. 


39 


CHAPTEE  VIII. 


NATURAL  HISTORY  AND    TREATMENT  OF  TUBERCULOSIS. 


I.     ETIOLOGY    OF    TUBERCULOSIS. 


Koch's  discovery  of  the  sisecific  bacillus  of  tuberculosis  has  brought 
about  a  reconstruction  of  jDathological  classificatiou  and  nomenclature  that 
commends  itself  by  clearness  and  simplicity.  Miliary  tuberculosis  of  the 
lungs  and  other  internal  organs,  scrofulous  affections  of  the  lymphatic 
glands,  the  various  forms  of  surgical  tuberculosis,  as,  for  instance,  white 
swelling  and  caries,  finally  the  several  forms  of  lupus,  are  manifestations  of 
one  and  the  same  mor- 
bid process — namely,  of 
cellular  decay  caused  by 
the  deleterious  influence 
of  a  vegetable  parasite, 
Koch's  tubercle  bacillus. 

The  identity  of  this 
bacillus  can  be  indubi- 
tably established  by  cer- 
tain modes  of  staining. 
No  other  known  micro- 
organism will  be  affect- 
ed by  Koch's  or  Ehr- 
lich's  mode  of  staining 
like  the  tubercle  bacil- 
lus. It  appears  under 
the  microscope  as  a  blue, 
elongated  body  of  the 
length    of    half    a    red 

blood-corpuscle,  and  is  found  occupying  alone  or  in  company  with  other 
individuals  a  giant  cell  generally  located  in  the  center  of  a  fresh  tubercle. 
(Figs.  191,  192,  and  193.) 

The  distribution  of  the  tubercle  bacillus  is  very  unequal.  It  is  found  in 
large  numbers  where  the  invasion  of  the  disease  is  recent,  or  where  it  is 
rapidly  extending.  It  is  very  scanty  in  chronic  affections  like  glandular 
scrofulosis  or  lupus. 


Fi&.  191. 


-Miliary  tubercles  of  lung,  with  central  caseation 
"(50  diameters).     (Koch.) 


294 


RULES  OF  ASEPTIC   AND   ANTISEPTIC  SURGERY. 


Fig.  192. — Part  of  one  tubercle  from  foregoinsr 
illustration.  Bacilli  interspersed  between  nu- 
clei fTOi)  diameters).     (Koch.) 


The  peculiarity  of  the  tubercle  bacillus  is  to  incorporate  itself  with  a 
white  blood-corpuscle,  and  to  influence  it  in  such  a  manner  as  to  convert 
it  into  a  lymphoid  cell  of  somewhat  large  proportions.     This  cell  becomes 

sessile  in  some  part  of  the  body. 
After  a  while  new  lymphoid  cells 
appear  in  the  vicinity  of  the  first 
cell,  which  by  this  time  will  have 
grown  to  the  proportions  of  a  mul- 
tinuclear  giant  cell,  containing  a 
number  of  bacilli  (Fig.  195).  As 
the  infection  spreads  along  the  pe- 
riphery, peculiar  changes  are  seen 
to  occur  in  the  center  of  the  nodule 
composed  of  lymphoid  cells.  The 
nuclei  of  the  lymphoid  and  giant 
cells  lose  their  staining  capacity  and 
coagulate  into  a  granular  mass.  The 
bacilli  contained  within  them  dis- 
appear, leaving  behind,  however,  a 
crop  of  invisible  spores  that,  trans- 
ferred to  a  suitable  soil,  will  readily 
produce  a  new  growth  of  bacilli. 
With  the  formation  of  this  co- 
agulated mass  of  decayed  cell-elements  the  process  of  caseation  is  estab- 
lished. The  presence  of  this  mass  of  necrosed  tissue  acts  as  an  irritant 
upon  the  capillaries  of  the  vicinity,  and  a  wall  of  new-formed  granulation 
tissue  is  thrown  up  around  the  focus.  Should  the  infection  of  the  neighbor- 
ing tissues  occur  before  the  protecting  wall  of  new-formed  granulatinn  tissue 
is  completed,  exten- 
sive caseous  infil- 
tration will  be  the 
result. 

The  barrier  of 
new-formed  granu- 
lations is  also  liable, 
here  and  there,  to 
invasion  by  bacilli, 
and  therefore  casea- 
tion will  generally 
extend  in  a  rather 
irregular  manner. 

An  increased  ex- 
udation of  blood- 
serum    and    white 

blood -corpuscles  will  finally  bring  about  emulsificatioji  of  the  cheesy  focus, 
which  then  represents  the  beginning  of  a  cold  abscess. 


Fig.  193. 


-Part  of  miliary  tubercle  from  a  case  of  basilar  menin- 
gitis (700'diameters).     (Koch.) 


ETIOLOGY  OF  TUBEECULOSIS. 


295 


Fig.  194. — Giant  cell  containing  bacilli  taken  from 
miliary  tubercle  (700  diameters).     (Koch.) 


There  is  no  organ  of  the  hnmaii  body  that  is  exempt  from  the  possibility 
of  tnbercnlosis. 

Tlie  'predisposition  to  infection  by  the  ubiquitous  spores  of  the  bacillus 
of  tuberculosis  is  manifestly  increased  by  any  kind  of  deterioration  of  local 
or  general  bodily  vigor.  Mal- 
nutrition, whether  due  to  an  at- 
tack of  measles  or  the  whooping- 
cough,  or  to  a  chronic  catarrh 
of  the  infantile  gut  caused  by 
improper  nursing,  or  to  long- 
continued  suppuration  from  an 
osteomyelitic  sequestrum,  is,  as 
a  matter  of  actual  observation, 
very  often  followed  by  local  and 
general  tuberculosis. 

The  most  common  ivay  of  in- 
fection is  undoiidtedly  that  l)y 
the  lungs.  Catarrhal  affections 
of  the  bronchial  mucous  mem- 
brane, regularly  accomj)anied  by  superficial  denudations  of  the  epithelium, 
serve  as  portals  for  the  entrance  and  implantation  of  the  spores  of  the  bacil- 
lus. And,  as  the  deterioration  of  the  general  state  of  health  after  measles  is 
comhined  ivith  a  catarrhal  condition  of  the  bronchi,  infantile  tuberculosis  is 

most  commonly  acquired  after  this 
eruptive  disease.  For  unknown 
reasons  the  pulmonary  tissues  of 
children  do  rarely  become  involved 
in  serious  tubercular  trouble  ;  but 
the  virus  is  promptly  transmitted 
to  the  bronchial  lymphatic  glands 
(Fig.  195),  which  undergo  casea- 
tion, and,  on  account  of  their  close 
vicinity  to  the  thoracic  duct  and 
various  vessels,  serve  as  a  depot  for 
further  distribution. 

We  owe  to  Ponfick  proof  of  the 
fact  that  perforation  of  a  caseous 
focus  into  the  thoracic  duct  may 
cause  a  more  or  less  general  dissemination  of  tuberculosis.  Koch  himself 
has  demonstrated  another  manner  of  distribution  in  the  involvement  and 
caseation  of  arterial  walls.  But  the  most  common  way  of  systemic  tubercu- 
lar infection  was  found  by  Weigert  in  the  decay  of  the  walls  and  perforation 
into  the  lumen  of  veins,  which  generally  hold  very  intimate  anatomical  rela- 
tions to  caseous  glandular  tumors. 

Entrance  of  small  quantities  of  tubercular  virus  into  the  general  circu- 
lation bv  the  wavs  above  indicated  will  lead  to  local  tubercular  affections  of 


Fig.  19.5.— Giant  cell,  witli  radial  arrangement 
of  bacilli,  from  a  caseous  bronchial  gland 
(700  diameters).     (Koch.) 


29G 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


Tarious  organs,  as,,  for  instance,  the  bones,  testicle,  or  joints.     Massive  in- 
vasion, on  the  other  hand,  will  cause  fatal  general  miliary  tuberculosis. 

Tubercular  matter  carried  along  by  the  circulating  blood  is  most  apt  to 
he  arrested  and  to  become  sessile  in  the  vicinity  of  the  terminal  arteries. 
The  views  erjiressed  in  the  chapter  on  the  localization  of  acute  infectious 
osteomyelitis  seem  to  be  applicable  also  to  the  localization  of  the  tubercular 
process.     (Page  209.) 

Another  rarer  manner  of  tubercular  infection  is  that  by  lesions  of  the 
skin.  A  Jewish  circnmciser  suffering  from  pulmonary  and  faucial  tuber- 
culosis, communi- 
cated the  disease 
to  twelve  infants 
by  sucking  their 
preputial  wounds. 
This  used  to  be 
the  accepted  man- 
ner of  stanching 
haemorrhage  after 
ritual  circumcision 
in  former  times. 

Note.— In  1879  the 
author  was  the  victim  of 
local  tuberculosis  of  the 
pulp  of  the  thumb,  con- 
tracted by  the  infection 
of  a  small  cut  received 
durinjr  the  amputation  of 
a  thigh  for  tuberculosis 
of   the  knee-joint,  com- 
plicated with  larfre  tubercular  abscesses  of  the  thigh  and  of  the  medulla  of  the  femur.     A  case- 
ating  elevated  ulcer  of  the  thumb  developed  and  persisted  for  six  weeks.     The  complaint  healed 
after  the  final  detachment  and  expulsion  of  two  caseous  plugs. 

The  dissemination  of  tubercular  matter  during  surgical  operations,  done 
for  the  cure  of  the  complaint,  was  first  pointed  out  by  Koenig. 

It  is  well  known  that  death  by  general  tuberculosis  is  seen  to  follow 
exsection  of  the  hip-joint  with  especial  frequency.  Upon  this  circum- 
stance is  based  the  statistically  proved  fact  that  the  expectant  or  rather 
non-operative  treatment  of  this  complaint  yields  better  results  than  an 
active  operative  therapy. 

Note. — These  facts  find  a  realv  explanation  in  the  circumstances  under  which  most  early 
exsections  of  the  hip-Joint  are  carried  out.  The  depth  of  the  diseased  joint ;  the  difficulty  of 
liberating  the  head  of  the  femur,  still  held  down  firmly  by  undestroyed  ligaments ;  the  desire  of 
operating  subperiosteally,  that  is,  with  the  employment  of  a  good  deal  of  blunt  force ;  the  forci- 
ble manipulations  in  distending  the  edges  of  the  deep  wound  by  retractors — all  serve  to  propel 
any  freed  caseous  matter  into  the  cut  orifices  of  veins  and  lymphatics.  The  result  is  that,  by 
the  time  the  local  tuberculosis  combated  by  the  surgeon  is  healed,  the  patient  succumbs  to 
meningeal  or  pulmonary  tuberculosis,  probably  chargeable  to  operative  interference. 


Fig.  196. — Giant  cell  containing  one  bacillus  from  Fig.  191 
(700  diameters).     (Koch.) 


TREATMENT  OF  TUBEECULOSIS.  297 


II.     COMPLICATION    OF    TUBERCULOSIS    WITH    PYOGENIC    OR 
SUPPURATIVE    INFECTION. 

Tubercular  decay  of  tissues  by  caseation  is  a  generally  slow  process,  as 
long  as  the  affection  remains  subcutaneous — that  is,  occluded  from  access 
of  air  with  its  pyogenic  organisms.  But  let  a  tubercular  focus  of  the  lung 
perforate  into  a  broncbus,  or  let  a  group  of  caseous  glands,  or  a  cold  abscess 
communicating  with  a  distant  focus  of  the  spine  or  some  joint,  be  opened 
without  aseptic  precautions,  and  the  affection  will  have  at  once  entered 
upon  a  new  and  more  destructive  phase.  The  formerly  thin,  flocculent  dis- 
cbarge will  assume  a  more  purulent  character,  the  production  of  pus  will 
become  prodigious,  more  or  less  fever  will  set  in,  and  the  symptoms  of  a 
rapidly  progressive  local  destruction  of  tissue  accompanied  by  hectic,  will 
become  more  and  more  pronounced. 

A  new  infection  was  thus  implanted  upon  a  soil  already  impoverished  by 
ill-nutrition  and  preyed  upon  by  a  destructive  parasite.  To  the  slow  decay 
of  tuberculosis,  the  rapidly  disorganizing  forces  of  purulent  infection  were 
added.  The  seriousness  of  this  contingency  was  justly  comprehended  by 
old-time  surgeons,  who  abhorred  meddling  with  a  cold  abscess  or  any  covert 
strumous  affection.  Incision  of  a  cold  abscess  then  meant  purulent  infection 
of  the  cavity,  extending  to  the  often  inaccessible  jDrimary  focus  of  the  dis- 
ease, hectic  fever,  and  rapid  emaciation  and  decay  of  the  patient. 

Just  appreciation  of  these  remarks  will  at  once  impress  upon  the  mind 
the  great  necessity  of  aseptic  measures  in  our  ojaerative  dealings  with 
tubercular  affections. 


in.     TREATMENT     OF     TUBERCULOSIS. 

General  Principles. 

Considering  the  fact  that  about  seventy  per  cent  of  all  deaths  are  directly 
or  indirectly  caused  by  tuberculosis  of  various  organs,  principally  consump- 
tion, and  tbat  the  management  of  the  infectious  sputa  of  consumptives  is 
careless  in  tbe  extreme,  it  must  be  admitted  that  efforts  at  prevention  offer 
no  great  hope  of  success.  The  sputa  containing  active  bacilli  or  their  spores 
are  ejected  on  the  ground  or  floor,  dry  there,  and  are  converted  into  dust, 
which  will  penetrate  everywhere  and  will  cover  everything  with  its  deadly 
burden.  The  tent  of  the  Indian  and  the  palace  of  the  millionaire  are  pene- 
trated alike  by  dust  containing  dried  and  pulverized  sputa  of  consumptives, 
and  millions  of  spores  of  pyogenic  cocci,  derived  from  suppurating  wounds, 
the  discharges  of  which  are  carelessly  thrown  every  day  ujDon  the  ground, 
to  be  whirled  up  from  there  by  draughts  of  air. 

A  more  promising  line  of  prevention  can  be  cultivated  in  the  proper 
nourishment  and  regime  of  the  individual.  The  better  the  general  con- 
dition of  health,  the  fuller  and  more  abundant  the  blood  supply  of  this  or 
that  organ,  the  less  the  chance  of  its  becoming  the  seat  of  tuberculosis.     Or, 


298 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


if  passing  conditions  of  anaemia  caused  by  illness  or  loss  of  blood  have  led 
to  the  establishment  of  a  tubercular  focus,  raising  of  the  general  health  by 
proper  diet  and  exercise  in  the  pure  air  of  the  sea  or  of  high  mountains,  will 
check  and  often  wholly  eliminate  the  ravages  of  the  disease.  A  generous 
diet,  with  plenty  of  exercise  in  the  open  air,  is  the  best  preventive  and  sys- 
temic curative  of  tuberculosis.  To  the  observance  of  scrupulous  cleanliness 
in  the  household  and  in  our  personal  habits  must  also  be  acceded  a  great 
protective,  and  in  some  measure  a  curative  influejice. 

Local  Treatment  of  Tuberculosis. 

Knowledge  of  the  true  nature  of  the  various  forms  of  surgical  tubercu- 
losis has  led  to  a  clear  understanding  of  the  principles  governing  its  suc- 
cessful treatment.  Since  we  do  not  possess  any  therapeutic  agent  capable 
of  destroying  the  bacillus  of  tuberculosis  in  situ,  without  interfering  with 
the  tissues  that  harbor  it,  chemical  and  mechanical  influences  must  be 
brought  to  bear  upon  the  tuberculous  focus,  with  the  object  of  destroying 
and  removing  all  cell  elements  infested  with  the  specific  virus.  In  short, 
the  modern  treatment  of  local  tuberculosis  is  identical  with  that  accepted 
for  the  cure  of  mcilignant  neiv  growths  ;  it  consists  in  a  more  or  less  com- 
plete removal  of  the  affected  tissues  or  orgatis  by  caustics,  the  hiiife,  or  the 
gouge,  under  aseptic  precautions. 

1.  Cutaneous  Tuberculosis.  Lupus  (Fig.  197). — Various  chemical  caus- 
tics, the  actual  cautery,  and  excision  are  known  to  effect  a  cure  of  cuta- 
neous tuberculosis.  In- 
ternal medication  has  no 
effect  upon  it.  The  most 
destructive  forms  of  lupus 
are  those  representing  a 
complication  of  tubercu- 
losis with  pyogenic  infec- 
tion— as,  for  instance,  lu- 
pus  exedens.  The  miliary 
nodes  nearest  the  surface 
caseate,  break  down,  and 
perforate,  and  the  way 
is  open  for  the  entrance 
of  pus-generating  cocci. 
Lupus  of  the  face  should 
be  treated  by  caustics 
and  scooping.  The  more 
radical  treatment  by  ex- 
cision is  not  to  be  commended  in  facial  lupus  on  account  of  the  disfigure- 
ment it  is  apt  to  cause.  Relapses  are  frequent,  and  should  be  attacked  over 
and  over  again  as  soon  as  they  appear.  Lupus  of  non-exposed  parts  of  the 
skin  should  be  exsected.  The  following  case  demonstrates  the  identity  of 
lupus  and  tuberculosis  : 


wy 


^.  :<p- 


0 


Jifi^ 


Fig.  197. — Section  of  lupoas  skin.     Giant  cell  containing 
one  bacillus  (TOO  diameters).     (Koch.) 


TEEATMENT  OF  TUBERCULOSIS.  299 

Case. — Otto  Krim,  aged  five.  Lupus  exedens  over  the  left  external  malleolus  of  the 
size  of  a  silver  dollar.  The  affection  existed  for  nearly  three  years;  about  a  year  ago 
glandular  swelling  appeared  in  Scarpa's  triangle  of  the  left  side  and  in  the  correspond- 
ing groin.  Extensive  scrofulous  ulceration  of  the  skin  followed,  and  caseous  glands 
lay  exposed  in  the  bottom  of  the  inguinal  wound.  February  4,  iSS7.— Extirpation  of 
the  lupous  patch  and  of  the  glandular  masses  from  Scarpa's  triangle  and  above  Pou- 
part's  ligament.  The  peritonaeum  was  exposed,  and  had  to  be  stripped  up  to  the  ex- 
ternal iliac  vessels  to  permit  complete  removal  of  the  glands.  Primary  union  of  the 
wounds  about  Poupart's  ligament.  The  malleolar  wound  healed  under  a  Schede  dress- 
ing.    February  27t}i. — Patient  discharged  cured. 

2.  Tuberculosis  of  the  Mucous  Membranes.  —  Scrofulous  rhinitis,  or 
coryza,  is  a  very  rebellious  affection  of  the  nasal  mucous  membrane.  It  is 
easily  recognized  by  the  chronic  swelling  of  the  mucous  covering  of  the 
nasal  cavity,  the  swollen  upper  lip,  open  mouth,  hard  hearing,  and  noisy 
breathing.  Its  surgical  importance  lies  in  its  tendency  to  produce  an  early 
affection  of  the  cervical  lymphatic  glands — scrofula.  Ulcerative  destruc- 
tion of  the  mucous  covering  of  the  nasal  bones  opens  the  way  for  the  ingress 
of  pyogenic  organisms,  which  bring  about  frequently  more  or  less  extensive 
necrosis.  An  intensely  fetid  odor  makes  the  breath  of  these  patients  in- 
tolerable. Termination  of  this  condition  is  best  accomplished  by  removal 
of  the  necrosed  bones  in  Rose's  dependent  position  of  the  head  (see  Fig. 
170).  The  sequestra  are  easily  dislodged  by  the  sharp  spoon.  The  haemor- 
rhage is  at  first  rather  profuse,  but  soon  subsides  on  irrigation  with  ice- 
water.  Daily  instillation  of  the  nasal  cavity  with  a  mild  solution  of  corro- 
sive sublimate  (1  :  5,000)  should  be  used  until  discharges  cease  to  appear. 

Tuberculosis  of  the  anal  mucous  membrane  is  a  most  frequent  cause  of 
tuberculous _^5^f^^?a  in  ano.  Simple  slitting  up  of  these  fistulous  tracks,  lined 
with  caseous  granulations,  and  often  dotted  with  miliary  tubercle,  will  not 
accomplish  their  cure.  Every  nook  and  recess  of  the  fistula  must  be  carefully 
explored,  and  all  caseous  or  granular  matter  must  be  removed  by  vigorous 
scooping  and,  if  need  be,  excision.  A  thorough-going  operation  will  always 
be  followed  by  improvement,  and  in  not  too  extensive  cases  by  local  cure. 

Tuberculosis  of  the  urethra  and  bladder  is  a  most  distressing  complaint, 
and  is  hardly  amenable  to  any  form  of  treatment.  Sedatives  and,  in  cases 
where  the  affection  of  the  neck  of  the  bladder  renders  life  intolerable  on 
account  of  the  unceasing  painful  strangury,  median  perineal  cystotomy,  fol- 
lowed by  drainage,  are  indicated. 

A  common  sequel  of  urethral  tuberculosis  is  caseous  eiMidymitis  and 
orchitis.  Testicular  tuberculosis  caused  by  urethral  disease  is  generally 
bilateral.  Single  tuberculosis  of  the  testicle,  on  the  other  hand,  is  gener- 
ally of  embolic  origin.     Its  sovereign  remedy  is  castration. 

3.  Tuberculosis  of  Lymphatic  Glands,  or  Scrofula  (Fig.  198).— Caseous 
chronic  lymphadenitis  is  one  of  the  most  common  affections  of  childhood  and 
adolescence.  Its  foundations  are  generally  laid  by  chronic  affections  of  the  oral, 
nasal,  and  aural  mucous  membranes,  by  tubercular  affections  of  the  cervical 
vertebra,  and  by  lupus  and  eczema  of  the  face  and  scalp.    The  incipient  stages 


40 


300 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


of  the  trouble  can  sometimes  be  controlled  by  timely  attention  to  the  causal 
disorders,  an  appropriate  general  treatment,  and  the  local  application  of 
one  or  another  preparation  containing  iodine  in  the  shape  of  an  ointment. 

As  soon  as  caseation  has  been  well  established,  general  and  topical  treat- 
ment of  the  milder  sort  will  be  of  no  avail. 

The  modern  therapy  of  scrofulous  lymphatic  glands  is  dominated  by 
the  idea  that  they  are  not  only  the  cause  of  present  discomfort  and  suf- 
fering to  the  patient,  but  especially  that  within  them  is  contained  the  seed 
for  renewed  infection,  which  by  its  dissemination  through  the  circulation 
may  cause  other  local  affections  or  a  fatal  general  malady.  The  close  ana- 
tomical relation  of  most  lymphatic  glands  to  important  venous  trunks  or 
their  immediate  affluents  renders  their  early  attachment  by  inflammatory 
deposit  very  easy.      Cheesy  degeneration   will   ultimately  reach   the  wall 

of   the  vein  itself,  and  dissemina- 


tion  of  the  tubercular  virus  through 
the  circulation  is  the  result. 

The  surgical  therapy  of  cheesy 
lymphadenitis  will  have  to  be  varied 
according  to  the  stage  of  the  dis- 
ease, the  chief  object  being  always 
thorough  removal  or  destruction  of 
all  infected  tissues. 

Where  there  is  central  caseation 
only,  and  no  fistula,  nor  an  appre- 
ciable abscess,  lodily  excision  of 
the  gkmdular  masses  is  most  appro- 
priate. The  neck  being  the  most 
common  seat  of  the  trouble,  a  few 
words  may  be  said  regarding  the 
detail  of  the  operative  treatment  of 
scrofulous  cervical  glands. 

The  incision  should  be  ample, 
and,  if  the  tumors  be  very  exten- 
sive, the  formation  of  a  flap  is  advisable.  The  capsule  of  the  uppermost 
gland  being  split,  the  glandular  body  is  shelled  out  of  its  nest.  This  is 
much  facilitated  by  an  assistant's  holding  aside  the  detached  capsule  with 
a  small,  sharp  retractor  while  the  surgeon  suitably  changes  the  position  of 
the  mass  by  turning  it  one  way,  then  another,  until  all  the  looser  attach- 
ments are  divided.  Great  care  must  be  exercised  herein  not  to  lacerate  or 
crush  the  brittle  substance  of  the  gland. 

Each  gland  has  its  afferent  and  efferent  vessels,  and  these  form  a  sort  of 
pedicle,  which  must  be  tied  off  before  it  is  cut. 

In  cases  of  very  extensive  involvement  of  the  cervical  glands  situated 
both  in  the  vascular  and  intermuscular  interspaces  (see  page  208),  it  is  very 
advisable  to  cut  the  sterno-mastoid  muscle  across  and  in  tivo.  The  si^inal 
accessory  nerve  will  be  found  near  its  posterior  margin,  and  should  be  saved. 


I'i'r.  r.''^.— Giant  cell  containing,'  one  bacillus 
from  a  scrofulous  gland  of  the  neck  (700 
diameters).     (Koch.) 


TREATMENT  OF  TUBERCULOSIS.  301 

The  stumps  of  the  divided  steruo-mastoid  muscle  are  raised  from  their 
proximal  attachments,  and  one  is  turned  up,  the  other  is  turned  down. 
The  otherwise  difficult  and  even  dangerous  dissection  of  the  glands  from 
the  vicinity  of  the  large  vessels  is  made  much  easier  by  the  free  exposure 
afforded  by  cutting  the  sterno-raastoid,  which  should  be  reunited  by  a 
number  of  catgut  stitches  after  the  completion  of  the  exsection. 

The  manner  of  placing  the  drainage-tubes,  the  suture,  and  dressings, 
do  not  differ  from  the  usual  arrangement.  Before  closing  the  wound,  a 
thorough  mopping  out  with  a  strong  solution  (1 :  500)  of  corrosive  subli- 
mate is  necessary,  to  make  sure  of  destroying  all  spores  of  tubercle  bacilli 
that  may  have  escaped  with  cheesy  matter  from  accidentally  injured  glands. 

When  dealing  with  progressed  central  cheesy  abscesses  of  the  cervical 
glands,  a  different  course  must  be  pursued.  Incision  of  each  abscess,  fol- 
lowed by  a  thorough  scooping  away  of  all  granulations  and  broken-down 
glandular  tissue,  is  the  proper  treatment.  The  sharp  spoon  can  and  should 
le  used  rather  vigorously,  and  no  fear  need  be  felt  of  injuring  large  vessels 
lying  close  by  the  walls  of  the  abscesses,  as  there  is  a  tough  and  thick  wall  of 
organized  connective  tissue  interposed  to  protect  them.  A  drainage-tube  is 
to  be  inserted  into  each  cavity. 

Caseous  abscesses  that  have  perforated  spontaneously,  or  have  been 
opened  inadequately,  generally  lead  to  tubercular  infection  of  the  subcuta- 
neous tissue  in  the  vicinity  of  the  aperture.  More  or  less  extensive  under- 
mining and  bluish  discoloration  of  the  shin  are  the  consequence.  The  un- 
aermined,  irregular  edges  show  very  little  tendency  to  heal ;  they  become 
inverted,  and  if  healed,  present  an  ill-shapen,  uneven  scar. 

To  aid  and  hasten  the  inadequate  efforts  of  Nature,  it  is  necessary  to 
extirpate  or  gouge  out  the  glandular  bodies,  to  trim  away  all  the  under- 
mined j)ortions  of  skin  with  the  curved  scissors,  2Jaying  no  regard  to  the  ex- 
tent of  the  resuliing  luound.  However  large  the  denudation,  it  will  heal 
rapidly  and  kindly  under  Schede's  dressing,  and,  on  account  of  the  mo- 
bility and  abundance  of  the  cervical  integument,  the  resulting  cicatrix  will 
be  nearly  linear  in  shape. 

XoTE. — Glandular,  cheesy  abscesses  on  the  necks  of  grown  girls  can  be  healed,  without 
leaving  a  conspicuous  scar,  by  repeated  punctures  with  a  stout  aspirating-needle.  The  contents 
of  the  abscess  being  removed  by  aspiration,  corrosive-sublimate  lotion  is  injected  through  the 
cannula,  and  is  again  withdrawn.  This  is  repeated  until  the  lotion  returns  clear  and  limpid, 
when  the  cannula  is  taken  out.  The  puncture-hole  is  protected  by  a  drop  of  iodoformed  collo- 
dion. The  process  is  repeated  whenever  the  abscess  refills,  until  the  cavity  becomes  closed. 
The  author  has  cured  two  cases  in  this  manner. 

4.  Tuberculosis  of  Tendinous  Sheaths. — Weeping  sinew  or  acute  syno- 
vitis of  the  tendinous  sheaths  sometimes  degenerates  into  a  chronic  affection 
of  their  synovial  lining  known  under  the  name  of  proliferating  hygroma. 
This  rebellious  affection  is  characterized  by  an  elongated,  fluctuating, 
irregular  swelling  of  the  carpal  region.  It  is  painless,  but  impedes  the  free 
use  of  the  fingers.  The  swelling  is  due  to  a  gelatinous  thickening  of  the 
sheaths  of  the  sinews.     The  tendons  finally  become  adherent  to  the  degen- 


302  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


erated  mass,  thus  losing  their  free  mobility.  The  sacs  frequently  contain 
some  more  or  less  discolored  synovia,  and  sometimes  a  large  number  of  rice- 
kernel-shaped  concretions  of  fibrin. 


Fig.  199. — Group  illustratiug  an  exsection  of  tubercular  tcndiuous  !<heaths  of  the  palm. 

Topical  applications  make  no  impression  upon  this  disorder,  which  can 
be  cured  only  by  free  incision  and  methodical  removal  of  the  fibrinous 
bodies  and  the  gelatinous  sheaths  by  careful  dissection  in  artificial  anaemia. 
If  the  new  growth  extend  underneath  the  transverse  carpal  ligament,  and 
can   not  be  got  at   otherwise,  the   ligament   must  be  divided  to  permit 

thorough  removal.  The  carpal  ligament, 
fascia,  and  skin  are  united  by  several  tiers  of 
catgut  sutures,  a  slit  is  left  open  at  each  end 
of  the  incision,  and  a  compressive  Schede's 
dressing  is  applied  to  the  arm  and  hand, 
which  should  be  placed  on  a  volar  splint  ex- 
tending to  the  line  of  the  metacarpo-phalan- 
geal  joints.  The  patient  is  directed  to  active- 
ly move  his  fingers  from  the  second  day  on, 
and  thus  to  fashion  grooves  in  the  blood-clot 
filling  the  interior  of  the  wound,  which  are 
to  become  new  tendinous  sheaths  after  the 
substitution  of  the  clot  by  new-formed  con- 
nective tissue.     (Figs.  199  and  200.) 

Case  I. — Samuel  H.,  medical  student,  aged 
twenty-five.  Tubercular  gelatinous  synovitis  of  all 
extensors  of  right  hand  and  of  flexors  of  left  hand. 
Uecemher  30, 1886. — Extirpation  of  diseased  sheaths 

Fig.  -200. — Lines  of  incision  on  pal-  of  extensor  tendons  of  right  hand  under  Esmarch  at 

mar  and  dorsal  aspects  of  the  hand  ,,  ^.      .  .^       .     ,      -,.  -,       „.  , 

for  tendineal  tuberculosis.     (Case  Mount  binai  Hospital.   /rtH««;-^  i^f^.— First  change 

of  Samuel  H.)  of  dressings  ;  primary  union.    By  January  20,  1887, 


TREATMENT  OF  TUBERCULOSIS.  303 

normal  function  re-established.  January  27th. — Similar  treatment  of  flexor  sheaths 
of  left  hand.  Double  ligature  and  division  of  superficial  palmar  arch  ;  division  of  car- 
pal ligament.  Suture  of  carpal  ligament,  fascia,  and  skin.  February  13th. — First 
change  of  dressings ;  primary  union.     March  15th. — Function  of  flexors  normal. 

Case  II. — Mina  Scheller,  aged  tvrenty-flve.  Tuberculous  synovitis  of  extensor  ten- 
dons of  both  hands.  March  26,  1886. — Operation  of  right  liand  at  Mount  Sinai  Hos- 
pital. Primary  union.  April  6th. — Operation  of  left  hand  ;  primary  union.  Janu- 
ary, 1887. — Function  of  both  hands  perfect. 

5.  Tuberculosis  of  Bone.  Caries.  Cold  Abscess.— Bone  tuberculosis  may 
appear  in  two  ways  :  On  one  hand,  it  is  either  an  independent  affection  of 
the  shaft  of  a  long  bone,,  preferably  in  the  vicinity  of  an  epiphyseal  line,  or 
it  is  a  deposit  in  the  epiphysis  itself,  which  by  extension  and  perforation  into 
the  joint  may  cause  tubercular  arthritis  ;  on  the  other  hand,  tubercular  in- 
volvement of  the  bone  may  be  caused  in  tubercular  arthritis  of  the  synovial 
type  by  ulceration  of  the  cartilage  and  direct  infection  of  the  exposed  bone. 
No  bone  is  wholly  exempt  from  tuberculosis.  The  skull,  the  spine,  the 
sternum,  ribs  and  scapula,  the  pelvis,  and  the  bones  of  the  extremities  are 
all  liable  to  infection. 

The  characteristic  features  of  idiopathic  bone  tuberculosis  are  thicken- 
ing, the  cheesy  deposit,  and,  later  on,  ulcerative  processes,  against  which 
the  exuberant  production  of  feeble  and  deciduous  granulations  conducts  an 
uneven  and  unsuccessful  struggle.  In  their  turn  the  granulations  also  be- 
come infected  and  succumb  to  cheesy  degeneration,  and  thus  the  process 
goes  on  interminably.  Sequestra  of  large  size,  as  in  acute  osteomyelitis, 
are  never  produced  ;  but  the  granulations  contain  smaller  or  larger  rudi- 
ments of  dead  bone,  and  a  good  deal  of  bony  grit  is  to  be  felt  in  the 
secretions. 

Cold  abscesses  represent  the  accumulated  result  of  cheesy  degeneration 
and  emulsification.  They  travel  by  well-known  routes,  and  the  surgeon  is 
generally  able  to  conclude  from  the  place  of  their  external  appearance  where 
their  source  is  to  be  looked  for. 

Cold  abscesses  contain  an  enormous  mass  of  infectious  matter.  They 
are  a  drain  upon  the  patient's  health,  and  should  be  therefore  always  evacu- 
ated. Evacuation  can  he  done  in  several  ways,  lut  it  must  under  all  circum- 
stances he  done  witli  strict  aseptic  precautions.  The  observance  of  asepticism 
is  of  especial  importance  wliere  the  focus  of  the  disease  is  inaccessible,  as 
for  instance  in  Pott's  disease. 

Note. — Evacuation  by  puncture  with  a  well-disinfected  trocar,  with  subsequent  injection  of 
a  solution  of  five  parts  of  iodoform  in  one  hundred  parts  of  ether,  was  proposed  by  Verneuil, 
and  has  been  found  very  effective  by  various  surgeons,  including  the  author.  The  injected  ether 
evaporates  in  and  distends  the  abscess  cavity.  Thus  the  iodoform  enters  every  nook  and  corner 
of  the  irregular  hollow,  where  it  exerts  the  undeniably  favorable  influence  of  all  iodides  upon 
the  tuberculous  process.  Undoubtedly,  abscess  cavities  thus  treated  fill  up  much  slower  than 
after  simple  evacuation.  Where  the  osteal  process  has  reached  its  termination,  they  do  not  re- 
fill at  all.  From  one  to  two  ounces  of  the  solution  are  to  be  used,  and,  after  thorough  disten- 
tion and  gentle  kneading  for  the  sake  of  even  distribution,  the  remnant  should  be  permitted  to 
escape  through  the  cannula. 


304  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

Cold  abscesses  situated  in  the  vicinity  of  accessible  foci,  as,  for  instance, 
near  the  ribs,  scapula,  or  about  the  extremities,  can  be  treated  much  more 
radically.  They  should  be  incised  to  their  full  extent,  and  their  pyogenic 
membrane  and  cheesy  contents  should  be  scraped  away  until  bleeding, 
healthy  tissue  is  reached.  After  this,  the  fistula  leading  from  the  abscess 
to  the  bone  is  searched,  and  the  exact  location  of  the  diseased  bone  is  ascer- 
tained. 

The  treatment  of  the  affection  of  the  bone  consists  in  free  exposure  and 
thorough  removal  of  all  portions  that  are  manifestly  in  a  state  of  ulceration 
or  cheesy  degeneration.  The  foci  are  made  accessible  by  a  free  use  of  the 
chisel  and  mallet.  The  sharp  spoon  and  gouge  must  clean  out  the  last 
vestige  of  granulating  or  cheesy  tissue,  until  the  bone  presents  a  healthy 
and  fresh  surface.  Finally,  the  external  wound  is  closed  by  suture,  due 
regard  being  jxaid  to  drainage,  and  the  parts  are  dressed  aseptically.  Thus 
primary  union  of  the  entire  wound  may  be  accomplished. 

The  following  example  may  serve  as  an  illustration  : 

Case. — Herman  Mehle,  barber,  aged  twenty-nine.  Large  cold  abscess  of  inter- 
scapular space  of  dorsum,  extending  under  the  left  scapula.  January  6,  1885. — In- 
cision, evacuation,  and  scraping  of  the  cavity.  A  sinus  leading  toward  the  transverse 
processes  of  the  second  and  third  thoracic  vertebrte  was  followed  up  by  incision,  and 
led  to  a  number  of  small  sequestra  belonging  to  the  heads  of  the  second  and  third  ribs. 
They  were  removed  by  gouging,  and  the  abscess  was  closed  by  suture.  Relapse  of  the 
cicatrices  re(juired  renewed  scrapings.     March  18th. — Patient  was  discharged  cured. 

Revision — that  is,  exj^loration  and  supplementary  removal  of  overlooked 
tuberculous  masses  by  gouging  and  scraping — is  a  very  necessary  and  per- 
fectly harmless  measure,  that  should  be  employed  within  three  or  four 
weeks  after  the  primary  operation,  in  case  the  remaining  sinuses  show  no 
tendency  to  heal.  The  appearance  of  exuberant  ulcerating  granulations 
about  the  orifices  of  the  drainage-holes  should  be  looked  upon  as  an  urgent 
indication  for  revision.  Anassthesia  can  be  rarely  dispensed  with  on  these 
occasions. 

Tuberculous  foci  in  the  vicinity  of  a  joint  are  a  great  menace  to  its  sound- 
ness. Early  detection  and  timely  evacuation  will  have  the  character  of  a 
truly  conservative  step.  The  diagnosis  of  a  single  and  central  cheesy  focus 
of  a  long  bone  is  not  easy  to  make  ;  but  the  lymphatic  habit  of  the  liatient, 
the  local  swelling  of  the  bone,  with  elevation  of  the  local  temperature  and 
distinct  spontaneous  and  pressure  pain,  may  serve  as  valuable  guides  to  its 
correct  ascertainment.  Slight  stiffness  of  the  joint  nearest  to  the  focus  in 
the  morning,  with  a  hardly  noticeable  limp,  which  becomes  more  marked 
toward  night,  are  significant  warnings  portending  the  gradual  breaking 
down  of  the  remnant  of  bone-tissue  serving  as  a  barrier  against  the  inva- 
sion of  the  joint. 

Where  cheesy  foci  are  suspected  in  the  vicinity  of  a  joint,  probatory  in- 
cision and  exploration  are  justified. 

In  cases  where  the  increasing  swelling  of  the  bone,  a  cold  abscess,  or  the 
presence  of  sinuses  with  fever  admit  no  doubt  regarding  the  nature  of  the 


TEEATMENT  OF  TUBEECULOSIS. 


305 


trouble,  free  incision  and  exposure  by  chisel  and  nnallet  must  be  practiced, 
followed  by  a  painstaking  removal  of  all  degenerated  tissues,  sequestra,  and 
cheesy  deposits.     The  subsequent  treatment  of  these  wounds  is  identical 
with  that  advised  after  necrotomy  for  osteomyelitic  sequestra. 
6.  Tuberculosis  of  Joints.    WMte  Swelling  : 


General  Part. 

Typical  tuberculous  arthritis,  caused  by  perforation  of  an  epiphyseal 
cheesy  focus  into  the  joint,  or  by  an  independent  infection  of  the  synovial 
membrane  from  a  distant  focus  (bronchial  glands)  by  way  of  the  general 
circulation,  is  popularly  known  as  loMte  swelling.  Mild  cases  of  children, 
treated  by  an  invigorating  regimen 


-.<§< 


--5^  ^ 


®  % 


Fig.  201.— Giant  cell  containing  two  bacilli 
from  fungoid  granulations  of  the  capsule 
of  the  hip-joint  in  morbus  coxarius  (700 
diameters).     (Koch.) 


and  proper  orthopedic  measures, 
will  yield  very  good  results  with- 
out serious  operative  interference. 

Even  when  ''starting  pains" 
indicate  loss  of  the  cartilaginous 
covering  and  caries  of  the  joint 
surfaces,  a  cure  by  anchylosis  or 
with  the  preservation  of  more  or 
less  mobility  is  possible.  Small  or 
great  periarticular  abscesses,  in- 
cised and  drained  under  aseptic 
cautelse,  "will  heal  kindly,  and  the 
ingrafting  of  the  more  intense  pu- 
rulent infection  upon  tissues  whose 
power  of  resistance  has  been  low- 
ered by  tuberculosis  and  disuse, 
will  be  avoided.  A  careless  incis- 
ion, or  a  spontaneous  perforation,  on  the  other  hand,  is  generally  the  start- 
ing-point of  widespread  destruction,  caused  by  suppurative  infection  from 
without.  Then,  to  conserve  the  limb  or  life  of  the  patient,  the  diseased 
joint  must  often  be  sacrificed. 

a.  Technique  of  Joixt  Exsectiok, — The  technical  rules  to  be  ob- 
served in  excising  joints  are  governed  by  the  following  requirements  : 

[a)  Septic  infection  from  loitTiout  must  le  excluded  by  strict  adherence 
to  the  rules  of  asepticism.  If  a  local  septic  condition,  due  to  purulent 
infection  by  uncleanly  management  of  a  cold  abscess  or  sinus,  be  present, 
this  has  to  be  first  eliminated  by  free  incision  and  drainage  of  burrowing 
phlegmonous  collections  and  by  frequent  irrigation.  Only  after  the  return 
of  the  temperature  to  nearly  the  normal  standard  is  exsection  permissible. 

XoTE. — Phlegmonous  inflammation  of  a  tuberculous  joint  is  a  much  more  serious  trouble 
than  that  of  a  previous  healthy  joint.  The  cavities  and  sinuses  preformed  by  the  tuberculous 
process  serve  to  disperse  the  new  poison  much  more  rapidly  and  widely  than  would  otherwise 
be  the  case.  Hence  the  formation  of  perforations  and  burrows  up  and  downward  between  the 
muscles  of  the  extremity  occurs  much   sooner  in  tuberculosis  than  happens  with  a  previously 


306  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

normal  capsule.  The  typical  mode  of  incision  and  drainage  of  the  knee-joint,  for  instance,  will  be 
found  insufficient  in  this  contingency,  and  multiple  perforation  into  the  popliteal  space  will  read- 
ily occur.  Exsection  of  a  knee-joint  subject  to  the  ravages  of  both  tuberculosis  and  intense 
phlegmon  will  offer  very  slender  chances  of  success,  and  amputation  will  have  to  be  decided  on. 

The  preservation  of  asepticism  is  gi'eatly  promoted  by  almost  continuous 
irrigation  of  the  wound  during  the  time  of  operation.  Corrosive  sublimate 
(1  :  3.000)  can  be  fearlessly  used  for  any  length  of  time  while  Esmarch's  con- 
strictor is  in  situ,  as  no  absorption  is  thus  possible  (Woelfler).  In  exsec- 
tions  done  witliout  artificial  ancemia,  very  loeaTc  solutiotis  of  corrosive 
sublimate  {1  :  5.000)  or  Thiersch's  lotion  should  he  employed.  At  the  con- 
clusion of  the  operation,  however,  the  wound  should  be  well  flushed  with 
stronger  (1  :  1,000)  corrosive-sublimate  solution. 

{h)  RemovaJ  of  all  parts,  soft  or  osseous,  that  are  manifestly  diseased, 
whether  carious,  cheesy,  gelatinous,  or  granulating,  is  a  most  important 
condition  of  success.  On  the  other  hand,  no  apparently  healthy  parts  ought 
to  be  needlessly  sacrificed. 

Note. — Without  antiseptics  partial  (xcisions  of  joints  were  much  more  dangerous  than  total 
ones.  The  reason  of  this  was  the  fact  that  after  total  exci.sion  the  conditions  for  effective  drainage 
were  much  better  than  after  partial  exsections.  Suppuration  of  resection  wounds  was  the  rule 
then,  and  is  now  the  exception,  hence  partial  excisions  are  just  as  safe  at  present  as  total  ones. 

To  prevent  further  dissemijiation  of  the  tubercular  virus  from  the  site 
of  the  operation,  ample  incisions  must  be  made.  They  will  enable  the  sur- 
geon to  reach  every  part  of  the  diseased  Joint  without  the  employment  of 
undue  force  by  retractors. 

Diseased  bones  are  removed  by  the  saw  in  adults  :  in  children,  they  can 
be  pared  off  with  a  strong  scalpel.  Pockets  filled  Avith  caseous  matter  are 
scooped  out  with  the  sharp  spoon.  The  entire  capsule  must  be  removed  by 
dissection  with  curved  scissors  and  a  mouse-tooth  forceps. 

(c)  To  control  hcemorrhage,  artificial  anaemia  should  be  used  during  the 
operation  wherever  possible.  Where,  as  in  the  shoulder-  and  hip-joints, 
Esmarch's  baud  can  not  be  well  applied,  each  vessel  must  be  secured  and 
tied  as  soon  as  it  is  exposed  or  cut. 

Artificial  ancemia  may  be  Icept  up  till  the  dressings  are  completed ;  but 
care  must  be  taken  to  search  out  and  tie  every  cut  vessel  before  closing  the 
wound.  How  to  do  this  is  described  in  the  paragraph  on  artificial  anaemia 
in  amputations  (page  69). 

{d)  Preservation  of  the  usefulness  of  the  limb,  or  of  the  function  of  the 
exsected  joint,  is  the  last,  but  not  least,  requirement  to  be  fulfilled. 

Tiie  knee-  and  occasionally  the  hip-joint  will,  as  a  rule,  be  more  useful 
if  firmly  anchylosed  than  otherwise.  Mobility  of  tlie  other  joints,  however 
limited,  is  more  desirable  than  anchylosis. 

To  favor  anchylosis,  the  sawed  surfaces  of  the  bones  to  be  united  must 
be  brought  and  kept  in  firm  apposition  by  posture,  suture  or  nails,  and  a 
eontentive  dressing. 

Where  preservation  of  mobility  is  aimed  at,  the  periosteal  covering  of 
the  exsected  bones  must  be  preserved  by  subperiosteal  dissection.     The  peri- 


TEEATMENT  OF  TUBERCULOSIS.  307 

osteum  can  be  stripped  off  easily  with  an  elevator  or  Sayre's  '^oyster-knife," 
except  at  the  site  of  the  insertion  of  muscles,  where  the  aid  of  the  scalpel 
or  a  sharp  raspatory  must  be  accepted.  The  re-formation  of  the  normal 
contour  and  function  of  the  prospective  joint  depends  in  a  great  measure 
upon  the  preservation  of  the  periosteum. 

With  drainage  by  rubber  tubes,  an  exact  suture  of  the  external  wound, 
and  Schede's  modification  of  the  aseptic  dry  dressing,  the  operation  is  com- 
pleted. Where  Esmarch's  constricting  band  was  left  in  situ  until  the  com- 
pletion of  the  dressings,  these  must  be  made  rather  ample,  and  a  good  deal 
of  elastic  pressure  by  snug  bandaging  must  be  brought  to  bear  upon  the 
wound  to  control  oozing  and  soiling  of  the  dressings.  The  dressed  limb 
must  be  suspended  or  otherwise  elevated  in  a  vertical  position  until  the 
hyperaemia  due  to  vascular  paresis  disappears.  Care  must  be  taken  to  ascer- 
tain, by  the  look  of  the  tips  of  the  toes  or  fingers,  that  circulation  is  not 
wholly  cut  off  by  strangulating  compression  of  the  bandage. 

Should  the  oozings  penetrate  the  dressing  in  the  course  of  a  few  hours, 
the  soiled  surface  of  the  bandage  must  be  thickly  dusted  with  iodoform  pow- 
der to  favor  exsiccation.  A  few  compresses  of  sublimated  gauze  are  placed 
over  the  bloody  spots,  and  are  secured  by  a  few  turns  of  a  roller  bandage. 

In  case  of  continued  oozing,  further  loss  of  blood  can  be  checked  by  the 
temporary  application  of  a  Martin's  elastic  bandage  over  the  dressings.  If 
the  soiling  is  too  extensive  to  admit  the  use  of  such  partial  measures  as 
those  just  indicated,  the  external  compresses  composing  the  dressing  must 
be  removed  and  replaced  by  clean  ones.  The  deepest  part  of  the  dressing, 
however,  should  not  he  disturbed. 

h.  Aftee-Teeatment. — Where,  as  for  instance,  in  the  elbow,  mobility 
of  the  joint  is  aimed  at,  absolute  fixation  by  splint  should  continue  only  so 
long  as  the  drainage-tubes  are  withdrawn  and  the  incisions  are  firmly 
healed.  Passive,  but  especially  early  passive  motions,  so  warmly  recom- 
mended by  older  authors,  are  harmful,  and  not  to  be  compared  as  regards 
their  value  with  active  exercises. 

The  disadvantages  of  early  passive  motions  can  be  summed  up  in  this  : 
Before  the  re-establishment  of  the  normal  condition  of  the  tissues  jaertain- 
ing  to  an  exsected  joint — that  is,  before  the  disapj)earance  of  the  swelling 
and  rigidity  of  the  soft  parts — all  motions,  active  and  passive,  will  be  jDain- 
ful.  Active  motions  will  be  limited  to  a  harmless  comjjass  by  the  pain  for- 
bidding extensive  movements  ;  but  passive  motions,  done  without  regard  to 
the  pain  and  struggles  of  the  resisting  patient,  will  be,  and  as  a  matter  of 
fact  often  are,  carried  far  beyond  the  limit  of  harmlessness.  The  forcible 
stretching  and  crushing  together  of  the  newly  united  parts  and  of  the  young 
connective  tissue  are  inevitably  followed  by  minute  ruptures  and  lacerations. 
Eenewed  exudation  and  a  diffuse  state  of  adhesive  inflammation  are  set  up, 
which  will  cause  the  persistence  or  even  an  increase  of  the  painful  swelling 
and  induration  primarily  found  about  the  exsected  joint.  The  greater  the 
surgeon's  energy  the  worse  the  result,  and  in  many  cases  anchylosis  is 
brought  on  by  the  very  measures  intended  to  prevent  it. 

41 


308 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


If  the  surgeon,  on  the  other  hand,  patiently  awaits  the  time  of  spontane- 
ous detumescence,  which,  with  antiseptic  measures  and  proper  fixation,  will 
occur  at  about  the  fourth  or  fifth  week  after  the  operation,  gentle  motions 
will  cause  no  pain,  and  will  encourage  the  patient  to  active  exercise  of  the 
joint.  The  pain  felt  on  excessive  movement  will  serve  as  a  wholesome 
check  against  undue  zeal ;  the  improvement  of  nutrition  due  to  active  exer- 
cise will  hasten  the  definitive  involution  of  the  inflammatory  products. 
Thus,  day  by  day  will  the  strength  and  amplitude  of  the  active  movements 
be  increased,  and  by  dint  of  painless  attrition  new  articular  surfaces  will  be 
ground  and  polished  into  shape.  The  psychological  and  moral  part  of  the 
after-treatment  is  of  the  greatest  importance  here.  The  conviction  that 
active  movements  of  the  exsected  Joint  are  possible  without  pain  ivill  ifispire 
the  patient  loith  courage.  Unceasing  active  exertion  will  work  wonders, 
based  upon  the  patient's  confident  expectation  of  a  good  final  result. 

The  acute  pain  produced  by  frequent  and  merciless  passive  motion,  and 
the  subsequent  tenderness  engendered  by  it,  will  convert  the  after-treatment 
to  a  source  of  constant  terror  and  moral  depression  to  the  patient.  His 
courage  will  be  shattered,  and  no  amount  of  persuasion  or  coercion  will  in- 
duce him  to  inflict  pain  upon  himself  by  active  movements.  And  it  will 
be  a  lucky  circumstance  if  the  physician's  ill-conceived  attempts  at  estab- 
lishing a  normal  function  are  frustrated  at  an  early  date  by  the  patient's 
resistance.  Subsequently,  rest  and  the  disappearance  of  local  pain  will 
naturally  elicit  first  timid,  later  bolder,  attempts  at  active  movement,  and 
after  all,  an  unexpectedly  good  function  may  thus  result. 

The  aid  afforded  to  Xature  should  be  very  discreet  indeed,  here  as  well 
as  in  other  branches  of  surgery. 

Aside  from  active  movements,  massage  and  faradism  are  powerful  aids 

in  re-establishing  normal 
circulation  and  lost  mus- 
cular power. 

Special  Part. 

a.   Shoulder  -  Joixt. 
— The  application  of  arti- 
ficial anjemia  in  exsection 
of  the  shoulder-joint  is  al- 
ways difficult   and  some- 
times   entirely    impracti- 
cable.    After  due  cleans- 
ing   and    disinfection    of 
the  field  of  operation,  the 
hand  and  forearm  of  the 
affected    limb   are   envel- 
oped in  a  clean  towel  wrung  out  of  mercuric  lotion  (Fig.  202),  and,  the 
rest  of  the  body  being  well  protected  by  rubber  sheets  and  clean  towels,  an 
ample  anterior  incision  is  carried  from  midway  between  the  acromion  and 


Fig.  202. — Exsection  of  shoulder-joint.     Head  of  humerus 
tui'ned  out  of  jflenoid  cavity. 


TREATMENT  OF  TUBERCULOSIS. 


309 


Fig.  203.- 


-Exsection  of  shoulder-joint.     Location  of  drainage  on 
the  posterior  aspect  of  the  shoulder. 


the  coracoid  process  down  to  the  limit  of  the  upper  third  of  the  humerus. 
The  tendon  of  the  long  head  of  the  biceps  is  held  aside  by  a  blunt  hook. 
The  capsular  ligament  and  periosteum  are  raised 
from  the  bone  by  means  of  an  elevator,  or,  where 
the  insertions  of  the  muscles  offer  greater  resistance, 
by  a  sharp  raspatory.  This  step  will  be  very  much 
facilitated  by  gradual  inward  and  later  by  outward 
rotation  of  the  humerus,  to  be  done  by  an  assistant 
holding  the  hand  and  bent  elbow.  After  deccqnta- 
tion  of  the  humerus, 
the  capsule  is  to  he 
exsected  iy  forceps 
and  Hunt  scissors. 
This,  the  most  diffi- 
cult part  of  the  op- 
eration, will  be  very 
easy  if  the  primary 
incision  is  am]3le.  If 
found  diseased,  the 
glenoid  fossa  is  thor- 
oughly scraped,  and, 
a  counter-incision  having  been  made  at  the  posterior  aspect  of  the  joint,  a 
drainage-tube  is  inserted  there.  (Fig.  203.)  The  first  incision  is  closed  by 
several  tiers  of  catgut  sutures,  and,  the  wound  being  dressed,  the  limb  is 
bandaged  to  the  thorax  in  a  flexed  position.  Later  on,  an  arm-sling  will 
serve  as  an  adequate  support.     (Figs.  204  and  205.) 

The  dressings  are  changed  on  the  fourth  day,  when  the  drainage-tube 
can  also  be  removed.  In  grown  subjects  the  operation  will  generally  result 
in  a  somewhat  loose  joint,  lacking  especially  the  power  of  active  abduction. 

Case  I.— Anna  Haupt,  aged  sixty.  Large  subdeltoid  cold  abscess;  no  fistula. 
May  25,  1879. — Exsection  of  right  shoulder-joint  at  the  German  Hospital.  Head 
of  humerus  bare  of  cartilage  and  carious ;  caries 
of  glenoid  cavity.     August  3d. — Discharged   cured. 

Case  II. — Willie  Kunz,  aged  four. 
January  25,  1882. — Exsection  of  left 
shoulder-joint  for  cheesy  osteitis  of  the 
head  of  humerus  at  the  German  Dis- 
pensary. March  10th. — Discharged 
cured. 

Case  III.—  August  Arnold,  aged 
three  and  a  half  years.  April  17, 
1883. — Exsection  of  left  shoulder- 
joint  for  caseous  foci  in  the  head  of 
the  humerus  at  the  German  Hos- 
pital.   May  30th. — Discharged  cured. 

Case   IV. — Harry  Gross,   aged  two 


Fia.  204. — First  dressing  after  exsection  of 
shoulder-joint. 


Septemler  30,   188Jf.  —  Exsection   of  right 
shoulder-joint  for  caseous  osteitis  at  Mount  Sinai  Hospital.     Several  relapses  required 


310 


RULES  OF  ASEPTIC  AND   ANTISEPTIC   SURGERY. 


Fig.  205. — Arm-sling.     (Esmareli. ) 


renewed  scraping  of  the  fungous  granulations.     January  15,   1885. — Patient  died  of 
meningeal  and  peritoneal  tuberculosis  with  ascites. 

Case  V.— Carl  Buchowsky,  type-setter,  aged  twenty-eight.     Synovial  tuberculosis 
of  right  shoulder-joint  of  si.x  years'  standing ;  three  fistuhe.     April  26,  1887. — Exsec- 
tion  of  the  slioulder-joint  at  the  German  Hospital.     In  May,  patient  was  discharged 
not  cured,  with  two  fistuL-e,  but  with   a 
very  fair  prospect  of  an  ultimate  cure,  the  * 

cause  of  his  discharge  being  a  disciplinary 
breach  of  the  rules  of  the  hospital. 

Case  VI. — Mr.  Robert  N.,  merchant, 
aged  thirty-three.  Had  been  sntfering  from 
chronic  pulmonary  trouble  for  many  years ; 
contracted  tuberculous  arthritis  of  right 
shoulder-joint  in  1882,  a  fistula  existing 
since  November,  1889.  Excision  of  shoul- 
der-joint April  16, 1890,  by  a  lateral  incis- 
ion, carried  through  the  middle  of  deltoid 
muscle.  Though  dissection  of  attachments 
of  the  muscles  to  the  tuberosities  was  diffi- 
cult, the  labor  was  repaid  by  the  care  with 
which  the  entire  capsule  could  be  excised. 
Patient  was  discharged  cured,  May  20, 1889. 

1).  Elbow. — The  patient's  shoul- 
der, hand,  and  part  of  his  forearm  are  wrapped  in  clean  towels  soaked  in 
corrosive-sublimate  lotion.  (Fig.  206.)  The  arm  is  vertically  elevated  for  a 
few  minutes,  and  elastic  constriction  is  applied  to  the  humerus  below  the 
shoulder.  Langenbeck's  posterior  longitudinal  incision  will  give  most  space, 
(Fig.  207.)  In  denuding  the  internal  epicondyle,  injury  of  the  ulnar  nerve 
should  be  guarded  against  by  closely  hugging  the  bone  with  the  instrument. 
The  diseased  portions  of  the  bones  being  removed,  the  entire  capsular  liga- 
ment is  exsected,  care  being  taken  not  to  overlook  any 
cheesy  foci.  One  or  more  drainage-tubes  are  inserted, 
j)referably  through  pre-existing  sinuses,  and  the  incis- 
ion is  closed  by  catgut  sutures.  The  region  of  the  elbow 
is  enveloped  in  an  ample  Schede's  dressing,  held  down 
by  rather  tight  bandaging.  The  extended  arm  is  fast- 
ened to  a  ])air  of 
lateral  pasteboard 
splints,  and  is 
kept  in  the  verti- 
cal position  till 
the  flushed  ap- 
pearance of  the 
projecting  tips  of 
the  fingers  due  to 
vascular  j^aralysis 
luis    disappeared. 

i"iG.  206. — Ex3ection  of  elbow-johit.     Patient  ready  for  operation.  (1^  Ig-   208.  ) 


TREATMENT  OF  TUBERCULOSIS. 


311 


Note. — The  simplest  way  of  making  suitable  pasteboard  splints  is  by  tearing  them  out 
of  a  sheet  of  pasteboard.  (Fig.  209.)  The  advantage  of  tearing  over  cutting  is  in  the  cir- 
cumstance that  the  edges  of  the  torn  splint  are  not  abrupt  and  hard,  but  become  soft  and 
then  on  account  of  the  gradual  thinning  of  the  torn  edge.     Snug  adaptation  and  a  good  fit  result 

therefrom.  Care 
must  be  taken  to 
ascertain  first  the 
trend  of  the  fiber 
of  the  pasteboard, 
as  the  edge  of  the 
splint  torn  across 
the  direction  of 
the  fiber  will  turn 
out  uneven,  and  a 
splint  thus  made  is 
apt  to  break. 

The  dress- 
ings should  be 
changed,  and 
the  drainage- 
tubes  removed, 
a  fortnight  aft- 
er the  exsec- 
tion.  The  el- 
bow is  to  be  re- 
dressed and 
|3ut  up  at  the 

same  angle.  As  soon  as  the  drainage-holes  are  healed,  passive,  but  espe- 
cially active,  exercises  should  commence,  aided  by  massage  and  faradism 
applied  to  the  muscles.  After  partial  exsection  of  the  Joint,  little  lateral 
mobility  will  be  observed.  In  these 
cases  no  special  apparatus  will  be 
required.     But  where  much  lateral 


Fig.  207. — Posterior  longitudinal  incision  ot  elbow-joint. 


Fig.  208. — Finished  dressing  and  eleva- 
tion after  exsection  of  elbow-joint. 


Fig-  209.— Tearing  into  shape  of  pasteboard  splint. 


312 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


mobility,  due  to  extensive  removal  of  bones,  is  present,  the  use  of  an 
apparatus  confining  the  movements  of  the  joint  to  flexion  and  extension 
will  be  required.     (Figs.  212,  213.) 

Note. — The  apparatus  can  be  made  by  the  surgeon  without  the  aid  of  the  instrument-maker 
in  the  follovving  manner:  Two  strips  of  very  light  hoop-iron  or  sheet-zinc,  about  one-inch  wide 
and  from  four  to  six  inches  long,  are  loosely  riveted  to  each  other  at  their  ends,  so  as  to  form  a 
hinge.  Two  pairs  of  such  hinges  are  necessary.  The  patient's  arm  being  protected  by  a  few 
turns  of  a  flannel  bandage,  a  light  silicate-of-soda  wristlet  and  arm-band  (Fig.  212)  are  applied. 
To  these  are  fitted  the  hinges,  one  externally,  the  other  internally,  by  giving  their  middle  a  suitable 
bend  to  allow  for  the  expansion  of  the  soft  tissues  on  flexion  of  the  joint  (see  front  view).     By 


Fig.  210. — Pattern  for  angular  pasteboard  splint.     (Esmarch.) 

a  few  more  turns  of  the  silicate  bandage,  the  hinges  will  become  immured  in  the  wristlet  and 
arm-band.  As  soon  as  the  splint  is  dry,  it  is  split  longitudinally  on  its  anterior  aspect,  to  per- 
mit its  removal  and  further  fitting.  Shoe  eyelets  are  put  in  along  the  edges  of  the  longitudinal 
cuts  for  lacing.  Two  pairs  of  small-sized  brass  screw-eyes  are  let  in  on  each  side  of  the  wristlet 
and  arm-band,  to  serve  for  the  attachment  of  solid  rubber  bands,  which  are  to  aid  the  efforts  of 
the  flexor  muscles  in  bending  the  ell)ow.  To  prevent  slipping  down  of  the  apparatus,  a  cap  is 
made  of  a  piece  of  sole-leather,  softened  in  hot  water,  which  is 
molded  to  the  shoulder.  It  is  left  on  till  dry.  A  button  is  let 
into  it  to  serve  for  suspending  from  it  the  apparatus  by  a  short 
strap.  Another  strap  slipped  over  this  button  is  passed  around  the 
thorax  of  the  patient,  and  is  buckled  in  the  opposite  axilla.  (Fig.  213.) 
Flexion  and  extension  are  to  be  done  by  the  patient  at  regular 
intervals  from  six  to  eight  times  a  day,  by  raising  first  an  empty  pail 
from  the  ground  twenty  or  thirty  times.  The  elbow  flexed  by  the 
rubber  bands  is  extended  by  the  weight  of  the  pail.    As  the  strength 


Fio.  211. — Angular  pasteboard  splint  in  situ.     (Esmarch.) 


of  the  flexors  improves,  active  flexion  is  to  be  tried,  and  the  weight  of  the  pail  is  to  be  gradu- 
ally increased  by  putting  more  and  more  sand  or  gravel  into  it.  The  apparatus  is  to  be  dally 
removed,  for  cleansing  and  the  application  of  massage  and  faradism  to  the  arm.  The  use  of 
the  apparatus  can  be  abandoned  with  the  disappearance  of  lateral  mobility. 


TREATMENT  OF  TUBERCULOSIS. 


313 


The  first  of  the  nine  cases  of  exsection  of  the  elbow-joint  performed  by 
the  author  was  done  without  aseptic  precautions.  Study  of  the  history  of 
this  case  and  comparison  with  the  other  cases  is  earnestly  recommended  to 
the  reader. 

Case  I.— Joseph  Keck,  silk-weaver,   aged  thirty-nine.      Synovial  tuberculosis  of 
right  elbow,  with  cold  abscess  situated  beneath  the  supinators;  no  fistula.     December 
10^  1877. — Total  exsection  of  the  joint  at  the  rooms  of  the  patient, 
without  any  aseptic  precautions.     Trochlea,  ulna,  and  radius  ca-        ^\ 
rious.     Drainage,  suture,  and  suspension  in  an  interrupted  wire  ^ 

splint.  "Wound  was  dressed  with  a  compress,  to  be  kept  moist  by 
immersion  in  tepid  water.  The  thermometer  indicated  103°  Fahr. 
ou  the  evening  of  the  same  day,  and  never  descended  below  this 
figure  until  December  24th.  Frequently  the  temperature  rose  to 
105°  Fahr.  December  13th. — Wound  fetid,  inflamed,  suppurating; 
stitches  were  removed,  whereupon  the  wound  gaped  open,  and  was 
seen  to  be  covered  with  a  thick,  adherent  coating.  December  15th. 
— Great  swelling  and  dusky  appearance  of  cubital  region.  Incision 
of  abscess  near  triceps  tendon.  December  17th. — Rigor,  elbow  stUl 
more  swollen.  December  18th. — Rigor.  December  19th. — Rigor 
and  great  debility.  December  22d. — Rigor.  December  2Ii.th. — 
Evacuation  of  another  abscess  from  the  upper  angle  of  the  wound, 
whereupon  the  temperature  fell  to  99°  Fahr.,  and  the  dusky  swell- 
ing of  the  limb  moderated.  Apparently  the  fever  was  due  to  osteo- 
myelitis of  the  lower  end  of  the  humerus.  December  25th. — Ery- 
sipelas set  in,  commencing  from  an  abrasion  caused  by  the  splint. 
Temperatm-e,  105°  Fahr.     December  29th. — Erysipelas  extended  to 

shoulder- joint,  where  it  dis- 
appeared. March  10th. — In- 
cised three  abscesses  of  the 
forearm,  wound  granulating 
and  contracting;  removal  of 
sequestrum  of  humerus.  June 
IJfth. — Removal  of  sis  small 
sequestra  from  humerus. 
Active  and  passive  move- 
ments commenced.  July 
12th.—Y\Qx\0Ti  to  90°;  ex- 
tension normal.  Sinuses  were 
scraped  in  angesthesia.  Lat- 
eral mobility  diminishing. 
September  29th. — Application 
of  articulating  apparatus.  October  30th. — Pa- 
tient was  discharged  cured,  with  normal  flexion 
and  extension,  with  limited  pronation  and  supi- 
nation, and  slight  lateral  mobility.  May  1887. — 
Ann  sound  and  quite  useful,  in  spite  of  slight 
lateral  mobility. 

Case  II.— Hermann  Prieg,  laborer,  aged  thirty-eight.  November  15,  1880.— 
Total  exsection  of  elbow-joint  at  the  German  Hospital  for  syno^nal  fungous  dis- 
ease with   fistula,   under  antiseptic   precautions.      Feverless   course,  primary  union. 


Fig.  212. — Appara- 
tus for  after-treat- 
ment of  exseetioD 
of  elbow-joint. 


-Elbow-joint  apparatus  in 
position. 


314  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

February  27th.— The   patient  was  discharged    cured,   with   limited    motion   and  no 
lateral  mobility. 

Case  III.— Lena  Bois,  aged  twelve.  Alarch  U,  iS5^.— Partial  exsection  of  elbow- 
joint  for  caseous  ostitis  of  the  olecranon,  from  which  a  sequestrum  was  removed  at 
tiie  German  Hospital.     April  30th.— Discharged  cured,  with  limited  motion. 

Case  IV.— Theodore  Noirot,  metal-worker,  aged  twenty-eight.  March  9,  1882.— 
Total  exsection  of  elbow-joint  at  the  German  Hospital  for  osseal  tuberculosis  of 
humerus,  ulna,  and  radius.  Primary  union  of  the  deep  i)arts  of  the  wound.  May  9th. 
— Discharged  cured  with  almost  perfect  function  of  the  new  joint. 

Case  V. — Leonliard  Path,  aged  seven.  Cheesy  tuberculosis  of  olecranon.  October 
^is?.— Partial  excision  at  Mount  Sinai  Hospital.  Kovember  iO«A.— Discharged  cured 
witli  limited  motion,  wliich  iniproved  somewhat  in  the  course  of  the  following  six 
months. 

Case  VI. — Luigi  Martini.  May  27,  1886. — Total  exsection  for  osseal  tuberculosis 
of  humerus,  ulna,  and  radius  at  the  German  Hospital.  Primary  union.  June  6th. — 
Discharged  cured  with  limited  motion.  Owing  to  neglect  of  the  parents,  who  failed 
to  present  the  boy  for  after-treatment,  the  joint  became  almost  entirely  stiff. 

Case  VII.— Charles  Dunninger,  aged  two  and  a  half.  April  22,  1886. — Total  ex- 
section  for  extensive  osseal  tuberculosis  at  the  German  Hospital.  Primary  union  and 
ultimately  excellent  function.  Discharged  cured  August  1st.  The  discharge  was 
delayed  by  the  inability  of  the  parents  to  take  care  of  the  child. 

Case  VIII. — Nathan  Blumenbach,  aged  seven.  Extensive  osseal  tuberculosis  with 
several  abscesses.  February  9,  1886. — Incision  and  drainage  of  the  abscesses,  followed 
by  severe  chill  and  fever,  very  likely  due  to  septic  infection  at  the  time  of  the  incision. 
February  11th. — Total  exsection  at  the  German  Hospital,  followed  by  prompt  low- 
ering of  the  temperature  from  10.5°  Fahr.  to  99°  Fahr.  Primary  union.  March  14th. — 
Discharged  cured,  with  good  function. 

Case  IX. — Rudolph  Boenke,  aged  twelve.  Cheesy  osteitis  of  olecranon  with 
abscess.  March  30th. — Partial  excision.  A  shell  of  the  olecranon  adhering  to  the 
triceps  tendon  was  preserved.  Suture ;  no  drainage-tabes.  April  12th. — Change  of 
dressings;  primary  union.  Elbow  put  up  at  a  right  angle.  April  IJ^th. — Passive 
motion  ;  fixation  at  an  acute  angle.  Every  few  days  passive  motions  were  done,  and 
the  arm  was  put  up  at  a  different  angle.  This  led  to  considerable  irritation  and  dense 
oedema  of  the  elbow,  compelling  cessation  of  the  passive  movements.  The  mistake 
made  in  the  after-treatment  was  further  emphasized  by  the  detachment  and  expulsion 
of  the  necrosed  remnant  of  the  olecranon.  Two  fistulse  discharging  bloody  serum 
remained  open.  May  30th. — The  fistuliB  were  scooped  out  with  the  sharp  spoon.  No 
improvement  following,  June  10th,  the  icound  teas  reopened  in  ether  anesthesia. 
Gelatinous  infiltration  of  the  soft  parts  surrounding  the  joint,  tuberculosis  of  the  radio- 
ulnar junction  and  caries  of  the  resected  bone-surfaces  were  found.  Total  exsection 
being  performed,  the  arm  was  dressed  and  put  up  in  a  splint  as  usual,  and  remained 
undisturbed  for  five  weeTcs,  after  which  active  exercises  were  commenced.  No  passive 
movements  were  done  at  all.  By  August  1st,  active  flexion  and  extension  were  normal, 
and  the  arm  had  regained  its  power  almost  completely. 

c.  Weist  axd  IIaxd. — Langenbeck's  dorsal  incision  affords  the  most 
favorable  approach  to  the  radio-carpal  as  well  as  especially  to  the  intercarpal 
and  metacarpo-carpal  joints.  (Fig.  214.)  With  artificial  anaemia  a  very 
thorough  removal  of  the  diseased  bones  and  capsular  ligaments  can  be  done. 
The  wound  is  drained  and  closed  by  catgut  sutures,  and,  being  inclosed  in 
an  aseptic  Schede's  dressing,  the  hand  is  fastened  to  a  short  volar  splint 


TREATMENT  OF  TUBERCULOSIS. 


515 


of  wood,  luliicli  sliould  not  extend  heyond  tlie  metacarpo-phalangecd  joints. 
The  patient  is  directed  from  the  second  day  on  to  practice  active  motions  of 
the  fingers.  This  will  achieve  two  good  purposes :  First,  extreme  atrophy 
of  the  muscles  will  be  prevented  ;  and  secondly,  adhesions  of  the  tendons 
and  tendineal  anchylosis  will  be  avoided.  The  active  movements,  feeble  and 
hardly  perceptible  at  first,  will  become  visibly  stronger  as  the  healing  jDro- 
gresses,  and  thus  a 
very  acceptable  degree 
of  usefulness  of  the 
hand  may  be  regained. 

Case  I. — Herman Ro- 
sengarden,  clerk,  aged 
thirty-four.  June  7, 1882. 
— Total  exsection  of  wrist 
at  Monnt  Sinai  Hospi- 
tal for  synovial  tubercu- 
losis with  several  fistulae. 
Primary  union.  August 
7th. — Discharged  cured. 
When  leaving,  he  played 
on  an  accordion. 

Case  H. — A  woman, 
aged    thirty-eight.     Au- 
gust 25, 1883.— Total  ex- 
section  of  left  wrist  at  the  German  Hospital. 
Discharged  cured,  with  moderate  function. 

Case  III. — Matthew  Dempsey,  laborer,  aged  twenty.  June  22, 1885. — Total  exsec- 
tion of  wrist  for  osseal  tuberculosis  of  carpal  bones  at  Mount  Sinai  Hospital.  Primary 
union  and  very  fair  function  were  secured.  The  discharge  of  the  jjatient  was  delayed 
till  the  end  of  the  year  by  several  pulmonary  haemorrhages. 

Case  IY. — Paul  Klein,  laborer,  aged  forty-one.  February  25,  1886. — Total  exsec- 
tion of  wrist  for  osseal  tuberculosis  with  several  fistulee  at  the  German  Hospital.  The 
patient  was  suffering  from  far-gone  pulmonary  phthisis.  Primary  union,  but  speedy 
relapse  of  tuberculosis  in  the  interior  of  the  wound  and  the  cicatrix.  April  lltJi. — 
Discharged  not  cured. 

Case  V. — Max  Friedmann,  aged  ten.  April  Iff h. — Partial  excision  of  wrist-joint 
on  account  of  caseous  osteitis  of  styloid  process  of  ulna,  with  involvement  of  the  radio- 
ulnar and  radio-carpal  joints.  Primary  union,  April  20th. — Discharged  cured,  with 
good  function. 

Case  YI. — Ferdinand  Ohle,  aged  five  and  a  half.  2Iarch  22d. — Total  exsection  ot 
left  wrist  at  the  German  Hospital  for  osseal  tuberculosis.  Wound  healed  by  primary 
union.  Patient  remained  in  hospital  for  treatment  of  simultaneous  tubercular  disease 
of  the  knee-joint. 

d.  HiP-.JOiXT. — "When  in  the  presence  of  proftisely  dischargmg  sinuses 
far-gone  destruction  of  the  hip-Joint,  especially  with  complication  of  the 
pelvis,  is  causing  much  suffering  and  a  steady  deterioration  of  the  general 
health,  excision  of  the  joint  is  clearly  indicated.  The  modus  procedendi  is 
as  follows :  The  ansesthetized  patient  is  laid  upon  his  side,  with  the  affected 
hip  uppermost,  the  hi]D-  and  knee-joints  lightly  bent,  and  a  solid  cushion, 

42 


Fig.  "214. — Langenbeck's  dorsal  incision  for  exsection  of  wrist. 


Primary  union.     Septeinber  SOtli. — 


316 


RULES   OF  ASEPTIC  AND   ANTISEPTIC  SURGERY. 


interposed  between  the  knees.  The  body  of  the  patient  is  carefully  pro- 
tected against  wetting  and  exposure  by  rubber  sheets,  and  the  hip  and 
buttock  are  shaved,  scrubbed,  and  disinfected.     A  longitudinal  incision, 

commencing   two    or   two   and   a 
half  inches  above  the  tip  of  the 
trochanter,  is  carried  down  to  the 
neck  of  the  femur,  until  the  mar- 
gin   of    the    acetabu- 
lum,  the   neck,   and 
the     trochanter    are 
well    exposed.      The 
cartilaginous  margin 
of      the      socket      is 
nicked,  and  the  soft 
tissues    attached    to 


Fig.  215.— Exsectinn  of  hip-ioint.     Position  of  patient. 


the  neck  of  the  femur  are  cut  away,  the  knife  closely  hugging  the  bone, 
an  assistant  aiding  this  procedure  by  inward  and  outward  rotation  of  the 
thigh.  The  head  of  the  femur  being  dislodged  by  flexion,  adduction,  and 
inward  rotation,  the  head,  neck,  and  trochanter  are  removed  by  the  saw  or 
a  strong  knife,  whereupon  the  capsule  is  carefully  excised  with  the  aid 
of  scissors  and  forceps,  and  the  acetabulum  and  sinuses  are  thoroughly 
scraped.  Cut  vessels  are  immediately  seized  and  deligated.  The  wound 
is  well  irrigated,  then,  after  insertion  of  a  drainage-tube,  is  packed  with 
strips  of  iodoform  gauze.     A  number  of  silkworm-gut  sutures  are  insert- 


FiG.  '217. — ('ompleted  dressing  after  hip-joint 
exsection. 


Fig.  216. — Exsection 
of  hip-joint.  Ar- 
ranirement  of  pro- 
tective cloths. 


ed,  but  remain  untied  for  future  use. 
An  ample  dressing  is  applied,  and  the 
limb  is  put  in  a  weight  extension  ap- 
paratus. On  the  third  or  fourth  day  the  gauze  packing  is  witlidrawn,  and 
the  sutures  are  closed.  During  the  after-treatment  the  limb  is  to  be  kept 
fully  extended  and  somewhat  abducted.  Should  exuberant  granulations 
appear,  they  have  to  be  scraped  away  Avitli  the  sharp  spoon.  As  soon  as 
the  wound  is  nearly  or  completely  healed,  the  patient  should  be  permitted 
to  exercise  on  crutches,  and,  when  his  strength  permits  it,  should  com- 


TEEATMENT  OF  TUBERCULOSIS. 


317 


mence  to  walk  in  a  Sayre's  or  Taylor's  apparatus.  This  will  prevent 
stretching  of  the  young  cicatrix  and  displacement  of  the  trochanter  upward. 
The  use  of  the  supporting  apparatus  should  not  be  abandoned  too  soon. 

Case  I. — Natlian  Spiegel,  aged  six.  Coxitis  of  two 
years'  standing.  Under  orthopsedic  treatment,  four  fis- 
tulse  developed.  August  9,  1887. — Excision  of  hip-joint 
at  Mount  Sinai  Hospital.  The  head  of  the  femur  was 
found  necrosed  and  detached.  Acetabulum  much  eroded. 
Discharged  cured,  witli  movable  joint,  December  22, 
1887. 

Case  II. — Sarah  Friedman,  aged  nine.  Coxitis  with 
unopened  femoral  abscess,  fever,  and  acute  starting 
pains,  which  do  not  yield  to  treatment  by  weight  exten- 
sion. September  1,  1887. — Excision  of  hip-joint  at  Mount 
Sinai  Hospital.  The  disease  was  mainly  acetabular,  a 
large  cheesy  focus  containing  two  sequestra  occupying 
the  posterior  aspect  of  the  socket.  Ligamentum  teres 
detached  from  acetabulum.  Discharged  cured,  with 
almost  perfect  motion  and  good  power,  January  15, 1888 
Case  III. — Minnie  Daly,  aged  sixteen.  Very  exten- 
sive hip-joint  disease,  which  had  been  badly  neglected 
while  the  child  was  under  purely  orthopaedic  treatment 
in  a  city  institution  devoted  to  that  branch  of  surgery. 
The  entire  buttock  and  the  pelvis 
presented  a  lamentable  picture  of 
a  system  of  ill-drained  cavities,  the 
chronic  retention  having  main- 
tained constant  fever  and  produced 
amyloid  intumescence  of  the  liver. 
The  urine  was  loaded  with  albu- 
men. In  spite  of  these  unpromis- 
ing facts,  the  author  deemed  it  his 
duty  to  make  an  attempt  at  saving 
life,  and  accordingly  excision  of 
the  hip  was  done  January  3,  1888, 
at  Mount  Sinai  Hospital.  The  necrosed  head  of  the  femur  was 
found  floating  in  a  cavity  freely  communicating  with  a  pelvic  ab- 
scess. The  operation  was  very  rapidly  accomplished,  and  with  the 
loss  of  very  little  blood,  but  the  wretched  patient  did  not  have 
enough  vitality  to  overcome  the  shock,  and  died,  January  4,  1888. 
Case  IV. — John  Cohn,  clerk,  aged  nineteen.  Ununited  fract- 
ure of  the  neck  of  the  femur,  with  incipient  tuberculosis  of  hip- 
joint.  Intracapular  fracture  was  sustained  in  March,  1888,  and 
was  treated  with  weiglit  extension  for  two  months.  On  failure 
of  union,  walking  was  attempted,  I  ■at  the  pain  caused  by  it  was 
unbearable.  August  6,  1888. — Exposure  and  removal  of  upper 
fragment.  Two  bony  facets  were  seen  on  the  surface  of  con- 
tact of  the  fragments.  The  acetabulum  was  filled  with  tubercu-  pjg_  219.  —  Hip-ioiut 
lous  brittle  granulations,  round  ligament  ulcerated  at  base.     Pa-  exsectioii.     Lateral 

tient  was  discharged  cured,  December  18,  1888.  y_  Lano-e.) 


Fig.  218.— Exsection  of  hip- 
joint.  Final  result.  Ante- 
rior view.  (Di.  F.  Lange's 
case.) 


318  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

Case  V. — Jacob  Weber,  aged  eight.  Acetabular  coxitis,  with  profusely  discharging 
sinus.  October  S4,  1888. — Excision  of  hip-joint  at  German  Hospital.  Perforation  of 
acetabulum  with  small  pelvic  abscess.     Discharged  cured,  April  7,  1889. 

Case  VI. — Albert  Gaupp,  aged  thirteen.  Anchylosed  hip-joint ;  caseous  ostitis  of 
OS  ilium,  with  complicated  sinuses  and  pelvic  abscess.  August  12,  1882. — Incision  and 
drainage  of  various  sinuses  and  of  the  pelvic  abscess;  removal  of  a  considerable  por- 
tion of  the  ilium  and  os  pubis  with  mallet  and  chisel  at  the  German  Ilosjjital.  Janu- 
ary 21,  1883. — Discharged  much  improved. 

Case  VII. — Samuel  Amster,  aged  ten.  Tubercular  coxitis,  with  sinus,  of  two  years' 
duration.  December  3,  1885. — Exsection  of  hip-joint  above  the  trochanters  at  Mount 
Sinai  Hospital.  Removal  of  the  acetabulum,  which  was  found  perforated.  After- 
treatment  with  weight  extension.  January  18  and  26,  1886. — Revisions  of  wound,  on 
account  of  the  presence  of  exuberant  granulations  in  the  drainage-tracks.  TTay  10th. — 
Discharged  cured.  In  November  the  patient  was  readmitted  on  account  of  pelvic  dis- 
ease. A  tistula  had  been  established  below  the  anterior-superior  spine,  leading  to  the 
inner  aspect  of  the  ilium.  December  15th. — Three  sequestra  were  removed  by  an  incision 
made  along  the  crest  of  the  ilium.     In  June,  1887,  the  patient  was  discharged  cured. 

Case  VIII. — John  Renk,  aged  thirty-nine.  Anchylosis  of  right  hip-joint,  with  short- 
enmg  of  limb,  the  result  of  hip  disease  contracted  in  childhood,  which  was  treated 
orthopedically.  No  fistula.  Tuberculous  ostitis  of  ilium  and  adjoining  part  of  os 
pubis.  March  17,  1887. — At  the  German  Hospital,  exsection  of  great  trochanter  and 
remnant  of  neck  of  thigh  as  a  means  to  gain  access  to  the  diseased  focus.  An  abscess 
was  opened  in  front  of  the  joint,  and,  being  followed  up,  led  to  a  number  of  seques- 
tra located  at  the  juncture  of  ilium  and  os  pubis,  which  were  removed.  The  softened 
and  broken-down  walls  of  the  cavity  containing  the  sequestra  were  scraped  and 
gouged.  Drainage  and  suture  of  the  wound.  Uneventful  course  of  healing.  In 
August  the  patient  was  still  under  treatment.  A  sinus  persisted  at  the  site  of  the 
operation.  The  discharge  was  very  scanty  and  serous,  however,  promising  early  clos- 
ure.    Anchylosis  firm  again.     Patient  walking  without  support.     Cured,  October  1st. 

The  frequency  of  miliary  tuberculosis  following  excision  of  the  hip-joint 
was  pointed  out  by  Koenig,  of  Gottingen,  who  attributed  it  to  an  ^' opera- 
tive dissemination"  of  the  virus.  If  a  small  incision  is  made,  and  much 
blunt  force  is  employed  by  the  use  of  retractors  and  the  elevator,  tubercu- 
lous material  deposited  in  the  lymphatics  in  the  neighborhood  of  the  joint 
is  projected  into  the  general  circulation,  and  may  usher  in  meningeal  or 
general  miliary  tuberculosis.  The  impossibility  of  here  applying  Esmarch's 
band  offers  another  plausible  explanation.  To  avoid  the  dissemination  of 
the  tuberculous  virus  during  excision  of  the  hip-  (and  shoulder-)  joint,  the 
following  rules  should  be  observed  : 

A  large  incision  deserves  the  preference,  as  by  it  the  diseased  jiarts  are 
freely  exposed,  and  can  be  attended  to  without  violent  manipulation. 
The  removal  of  the  capsule  can  be  rapidly  and  thoroughly  accomplished. 
The  knife,  and  not  the  elevator,  should  be  used  for  stripping  off  the  soft 
parts  from  the  neck  of  the  femur.  Likewise,  in  removing  the  capsule  the 
scissors  deserve  preference  over  the  scoop.  In  evacuating  cheesy  pockets 
located  within  the  os  ilium,  very  sharp-edged  scoops  are  to  be  used,  or 
preferably  a  gouge  and  the  mallet.  During  the  chiseling,  and  especially 
while  scraping,  the  irrigating  stream  should  continually  play  over  the  field 


TREATMENT  OF  TUBERCULOSIS.  319 

of  operation,  so  that  all  the  detached  material  may  at  once  be  washed 
away.  In  short,  we  may  say  that,  in  a  limited  sense,  the  same  rules  apply 
to  the  removal  of  tuberculous  as  to  the  eradication  of  cancerous  foci. 
The  surgeon  should  rely  uj)on  the  edge  of  his  cutting  instruments,  which 
should  be  carried  through  apparently  healthy  tissues  ;  he  should,  as  much 
as  possible,  avoid  the  employment  of  blunt  force  as  exercised  by  retract- 
ors and  the  elevator.  The  fulfillment  of  these  conditions  will  greatly 
diminish  the  danger  of  operative  dissemination  as  well  as  of  local  relapse. 
And  these  conditions  can  be  fulfilled  only  if  the  site  of  the  disease  is  laid 
bare  by  an  ample  incision. 

e.  Ki^EE-JOiNT.  —  White  swelling  of  the  knee-joint  in  adults  of  the 
laboring  class  can,  for  various  external  reasons,  rarely  be  treated  by  ortho- 
pedic measures.  In  children,  a  rational  mechanical  and  general  treatment 
will  often  reward  the  patience  and  skill  of  the  physician  by  excellent  results. 
Exsection  of  the  infantile  knee-joint  is  to  be  avoided  as  long  as  possible,  on 
account  of  the  great  shortening  that  is  caused  by  the  removal  of  the  epi- 
physes adjoining  the  knee,  on  which  depends  the  growth  of  the  thigh  and 
tibia.  In  adults  exsection  is  the  shortest  and  safest  way  of  eliminating  the 
tedious  morbid  process,  and  substituting  firm  anchylosis  for  a  useless  joint. 
Arthrectomy,  or  exsection  of  the  capsular  ligament  alone,  as  suggested  by 
Volkmann,  has  not  been  attended  with  good  success  in  the  experience  of 
the  author.  Two  cases — one  in  an  adult,  the  other  in  a  child — resulted  in 
relapse  of  the  tubercular  affection,  although  great  care  was  taken  in  remov- 
ing the  entire  capsule.     A  third  case  was  permanently  cured. 

Case  T. — S.  Liodholm,  metal-worker,  aged  twenty-seven.     February  S8,  1882. — 
Arthrectomy  and  removal  of  the  patella  were  done  for  fungous  arthritis  of  the  knee- 
joint.     Primary  union  of  wound  followed.     March  22d. — A  relapse  occurred  in  the 
cicatrix,  which  gradually  involved  the  articular  aspects  of  the  femur 
and  tibia.     Amputation  of  the  tbigh  was  performed  by  Dr.  I.  Adler. 

Case  II. — Fred.  Oble,  aged  five  and  a  half.  Tubercular  arthritis 
of  the  knee-joint.  January  26,  1887. — Arthrectomy  was  performed 
at  the  German  Hospital.  March  22d. — Revision  and  scraping  of  the 
entire  cavity  on  account  of  tubercular  relapse.  In  May  the  boy  was 
still  under  treatment. 

Case  III. — George  Kuhn,  butcher,  aged  twenty- six.  July  6,  1882. 
— Arthrectomy  and  removal  of  carious  patella  was  performed  at  the 
German  Hospital.  November  5th. — Discharged  cured  with  slight  mo- 
bility of  joint. 

In  children,  exsection  should  be  strictly  limited  to  the  re- 
moval of  actually  diseased  parts  of  the  bones.     By  Schede's 
plan  of  dressing  the  wound,  the  hollow  space  remaining  be-     Halm's 
tween  the  incongruent  joint-surfaces  will  be  filled  up  by  an       FoVfor  esfec- 
organizing  blood-clot,  and  firm  union  may  be  attained.  tion  of  knee- 

Case  IV. — Eva  Greenburg,  aged  eight.     Osseal  tuberculosis  of  the 
knee-joint  with  sequestrum  in  the  external  condyle;  granular  ostitis  of  the  internal 
condyle;  multiple  cheesy  deposits  in  the  thickened  capsule;  subluxation  backward  of 


320  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


tlie  tibia  witli  rectangular  contraction.     August  IS,  i5c^6.— Partial  exsection  of  knee- 
joint  at  Mount  Sinai  Hospital.     After  the  removal  of  the  sequestrum,  a  deep  recess 

was  left  behind  in  the  intercondy- 
lar notch.  Patella  and  entire  cap- 
sule were  removed ;  the  ham-string 
tendons  were  divided  to  prevent 
recontraction.  The  tibia  was  su- 
perficially pared,  and  the  bones 
were  held  in  apposition  by  a  nail 
driven  diagonally  through  femur  and 
tibia.  Plaster-of-Paris  splint  over 
a  Schede's  dressing.  Several  re- 
lapses in  the  popliteal  space  re- 
quired repeated  scrapings.  The  pa- 
tient had  one  attack  of  erysipelas. 
By  reason  of  these  complications, 
cure  was  delayed.  February  27, 
1887. — Patient  was  discharged  cured 
with  firm  anchylosis. 

Total  exsection  of  the  knee-joint  is  usually 
done  by  the  author  in  the  following  manner : 
After  careful  shaving,  scrubbing,  and  disinfec- 
tion of  the  region  of  the  knee,  the  foot  and  leg 
and  the  thigh  of  the  diseased 
limb  are  wrapped  in  clean 
towels  wrung  out  of  corrosive- 
sublimate  lotion.  The  limb  is  held  elevated  in  the  ver- 
tical position  for  five  minutes  to  deplete  its  vessels,  and 
the  constricting  elastic  band  is  applied  well  up  near  the 
root  of  the  thigh.  The  knee  is  flexed,  and  an  incision, 
commencing  at  the  middle  of  one  condyle  of  the  femur, 
and  extending  in  a  semicircular  line  above 
the  patella  to  the  middle  of  the  other  con- 
dyle, is  carried  into  the  Joint.     (Fig.  220.) 

Note.  —  The  transverse  incision 
above  the  patella,  proposed  by  Eugene 
Hahn,  of  Berlin,  has  many  advantages 
over  the  incision  made  below  the  knee- 
pan.  The  chief  one  is  the  free  access 
it  affords  to  the  bursa  of  the  quadri- 
ceps, which  must  be  carefully  exsected 
along  with  the  capsule. 

The  crucial  ligaments  are 
cut  close  to  their  attachment 
to  the  femur,  and  the  patella, 

semilunar  cartilages,  and  entire  capsule,  together  with  the  bursa  of  the 
quadriceps,  are  exsected  with  mouse-tooth  forceps  and  curved  scissors. 
Care  must  be  taken  not  to  overlook  some  small   bursae  situated  behind 


Fig.  221.— Exsection  of  knee- 
joint.  Exposure  of  articular 
planes. 


Fio.  222. 
Exsection  ot 
Ivuee  -  joint. 
A  view  of 
the  sawed 
surfaces. 


TEEATMENT  OF  TUBERCULOSIS. 


321 


Fig.  224.- 


-Exsection  of  knee-joint, 
view. 


Sutured  wound.     Anterior 


the  head  of  the  tibia,  which  regularly  communicate  with  the  interior  of 
the  joint. 

The  condyles  of  the  femur  are  sawed  off,  the  plane  of  section  correspond- 
ing to  the  transverse  diameter  of  the  epijohysis  of  the  femur.     (Fig.  222.) 

Note. — Disregard  of  this 
rule  will  lead  to  anchj'losis 
in  the  bow-leg  position. 

„i  ,  •       1  EiG.  223. — Steel  nail. 

The  articular  as- 
pect of  the  tibia  is  sawed  off  at  a  right  angle  to  the  long  axis  of  this  bone. 

All  visible  orifices  of  vessels  are  secured  by  ligature.     They  can  be  made 

visible  by  compress- 
ing the  vicinity  of 
the  wound  with  both 
hands. 

If  the  transverse 
incision  was  not  made 
long  enough  to  permit 
of  an  easy  arrangement 
of  the  drainage-tubes 
in   the  angles  of  the 

wound,  it  should  be  sufficiently  lengthened.     The  inner  ends  of  the  tubes 

should  reach  into  the  popliteal  space  just  behind  the  sawed  surfaces,  and  the 

tubes  must  not  be  compressed  and  occluded  by  the  tension  of  the  soft  parts 

surrounding  them. 

The  limb  is  placed  upon  a  long  cushion 

covered  with  a  clean  towel  wrung  out   of 

corrosive-sublimate   lotion,    and,    while   the 

sawed  surfaces  are  held  in  exact  apposition, 

two  or  four  long  steel  nails,  previously  well 

disinfected  by  heating  in  an  alcohol  flame, 

are  driven  diagonally 

through   femur  and 

tibia,  so  as  to  firmly 

lock    the    bones    in 

the  desired  position. 

(See   Fig.    79,   page 

87.)    The  cutaneous 

incision  is  united  by 

a  sufScient  number 

of    catgut    stitches. 

The   limb   is   raised 

by  the  foot  from  the 

cushion,     which     is 

then  removed.     Strips  of  disinfected  rubber  tissue  are  slipped  under  the 

safety-pins,  securing  the  ends  of  the  trimmed  drainage-tubes,  and  an  oblong 

compress  of  iodoformed  gauze  is  laid  over  the  entire  line  of  union.     A  suit- 


FiG.  225. — Exsection  of  knee-joint.     Sutured  wound._    Lateral  view. 
Heads  of  steel  nails  projecting  from  skin. 


322 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


Fig.  2iiG. — Immediate  dressing  of  wound  after 
exsection  of  knee-joint. 


able  number  of  sublimated  gauze  compresses  are  arranged  arouud  the  knee- 
joint,  and  two  short  lateral  splints  of  veneer  or  thin  board  are  firmly  band- 
aged on  to  serve  as  a  deep  support.  (Figs.  226  and  227.)  Over  these 
comes  an  ample  external  dressing  of  corrosive- 
sublimate  gauze,  also  firmly  held  down  by  a  gauze 
bandage.  The  towels  are  removed,  and  the  un- 
covered parts  of  the  limb  are  envelojoed  in  a  layer 
of  borated  cotton  to  equalize  the  outline  of  the 
extremity.  Two  long,  lateral,  pasteboard  splints, 
held  down  by  a  muslin  or  crino- 
line bandage,  comjDlete  the  dress- 
ing for  children  or  adolescents. 
(Fig.  228.)  The  more  voluminous 
limbs  of  adults  are  better  secured 
by  a  solid  circular  plaster-of- Paris 
splint. 

The  limb  is  vertically  elevated, 

and  the  constricting  rubber  baud 

is  removed.    Return  of  circulation 

is  attested  by  the  pink  color  of 

the  toes.     As  soon  as  these  turn  pale,  the  extremity  can  be  brought  into 

the  horizontal  position. 

If  asepticism  was  well  maintained,  little  aseptic  fever  and  no  severe 
pain  will  follow  the  operation.  The  dressings  should  remain  undisturbed 
for  thirty  days,  to  afford  a  good  chance  for  bony  union.  After  thirty  days 
the  splints  and  dressings  can  be  removed,  and  the  nails  and  drainage-tubes 
can  be  withdrawn.     The  remaining  sinuses  are  to  be  dressed  lightly,  the 

limb  is  incased  in  a  silicate-of-soda  splint,  and 
the  patient  is  ordered  to  walk  about  on  crutches, 
whether  osseous  union  be  present  or  not.  Gradu- 
ally the  use  of  crutches  is  dispensed  with,  and 
the  patients  generally  learn  to  walk  very  well  on 
an  elevated  sole,  compensating 
the  shortening. 

Of  twenty-one  cases  of  total 
exsection  done  by  the  author  for 
tuberculosis,  twenty  recovered. 
One  died  of  meningeal  tubercu- 
losis. 

Case  I. — Fred.  Fuchs.  aged  sev- 
en. Osseal  relapsing  tuberculosis 
after  arthrectomy,  done  by  Dr.  F. 
Lange  in  June,  1885.  March  ^ 
188Jf. — Total  exsection,  done  at  the 
German  Hospital,  reveals  two  periarticular  abscesses  and  five  cheesy  foci  in  tibia  and 
femur.     Suppuration  of  wound.     March  i6'?A.— Incision  of  abscess  on  outer  aspect  of 


Fig. 


-Deep  support  of  exseeted  knee-joint  by 
short  lateral  board  splints. 


TREATMENT  OF  TUBERCULOSIS. 


323 


Fig.  228. — External  long  lateral  pasteboard  splints  after  exsec- 
tion  of  knee-joint,  applied  over  complete  dressing. 


knee.      April  23d. — Separation  of  epiphysis  of  tibia.      Separated  epiphysis  firmly 
united  to  femur.     In  April  symptoms  of  meningeal  tuberculosis  developed,  to  which 

patient  succumbed  May  31st. 

In  two  of  the  remaining  twenty  cases  ampu- 
tation of  the  thigh  became  necessary  on  account 
of  suppuration. 

Case  II. — H.  Desmond,  professional  athlete,  aged 
thirty.  Extensive  destruction  of  right  knee-joint  by 
tuberculosis,  complicated  with  pyogenic 
infection.  The  knee,  leg,  and  thigh  con- 
tain a  large  number  of  abscesses.  Pro- 
fuse secretion  from  seven 
fistulse.  The  case  was  not 
suitable  for  exsection,  and 
amputation  was  advised. 
But,  at  the  patient's  ur- 
gent request  to  make  an 
attempt  to  save  his  limb, 
February  14,  1884,  total 
exsection  was  done  at  the 
German  Hospital.  As  sup- 
puration was  expected,  the 
extremity  was  fixed  to  an  interrupted  dorsal  suspension  splint  made  of  hoop-iron  and 
plaster  bandages.  Profuse  suppuration  followed  with  evident  prostration,  and,  April 
19th,  amputation  of  the  thigh  was  performed.  The  wound  healed  by  granulation,  and 
in  June  patient  was  discharged  cured. 

Case  III. — Johanna  Rose,  aged  thirty-nine.  Far-gone  destruction  of  knee-joint, 
five  fistulffi,  continued  fever.  As  the  patient  would  not  consent  to  amputation,  excis- 
ion was  done  October  16,  1888,  at  the  German  Hospital,  with  little  hope  of  success. 
The  fever  subsided,  however,  on  account  of  the  better  drainage,  but  reappearance  of 
the  tubercular  process  prevented  union.  An  amputation  was  done  by  Dr.  J.  Adler  in 
February,  1889.     The  patient  was  cured. 

Eighteen  patients  were  cured,  with  preservation  of  the  limb.  In  seven- 
teen of  these,  firm  bony  anchylosis  was  secured.  One  case  terminated  in 
the  formation  of  ligamentous  union. 

Case  I. — Niclas  Gies,  carpenter,  aged  fifty-four.  Synovial  tuberculosis  with  high 
temperatures  and  emaciation  following  a  slight  traumatism.  Contraction  of  knee  at 
an  acute  angle,  with  constant  violent  pain.  February  19,  1886. — At  the  German  Hos- 
pital, puncture  yielded  a  small  quantity  of  turbid  bloody  serum.  In  anaesthesia  the 
limb  was  straightened,  and  the  joint  was  incised,  irrigated,  and  drained.  The  fever  at 
once  disappeared,  but  flocculent  pus  commenced  to  exude  from  the  tubes,  confirming 
the  assumption  of  tuberculosis.  In  view  of  the  patient's  age,  his  wretched  general 
condition,  due  partly  to  disease  and  to  chronic  alcoholism,  amputation  was  thought  to 
be  advisable.  The  plan  of  operation  was  changed  at  the  operating-table,  and  total  ex- 
section  of  the  knee-joint  was  done.  Hsemorrhagic  synovitis  and  a  large  cheesy  deposit 
in  the  bursa  of  the  quadriceps  were  found.  Five  nails  were  employed,  with  an  aseptic 
dressing  and  pasteboard  splints.  Temporary  compression  by  Martin's  elastic  bandage 
was  applied  to  control  secondary  oozing.  Esmarch's  constrictor  was  removed  after 
the  completion  of  the  bandage.  A  feverless  course  of  healing  foUow^ed.  Change  of 
4S 


324  RULES  OF  ASEPTIC  AND   ANTISEPTIC  SURGERY. 

dressings  was  done  on  the  twenty-second  day.  Four  nails  were  found  loose,  and  were 
withdrawn.  May  8th. — Scraping  of  drainage-tracks  and  removal  of  fifth  nail.  Liga- 
mentous union  was  found  and  a  plaster  splint  applied.  June  12tli. — The  sinuses  were 
healed,  and  the  patient  was  walking,  without  the  aid  of  stick  or  crutches,  in  a  light 
silicate-of-soda  splint,  though  union  of  the  bones  was  not  perfect. 

The  other  sixteen  cases  were  in  brief  as  follows  : 

Case  II. — Willie  Bohn,  aged  three  and  a  half.  Osseal  tuberculosis  with  fistulte. 
February  2,  1879. — Total  exsection.     April  2d. — Patient  discharged  cured. 

Case  III. — Charles  Harris,  aged  twelve.  Osseal  tuberculosis  with  fistula) ;  con- 
tracture and  subluxation  backward.  June  IS.,  188Jf. — Total  exsection  at  the  German 
Hospital.  Hahn's  incision  ;  two  nails;  plaster-of-Plaster  splint.  Some  fever  and  deep- 
seated  ojdema  of  the  region  of  the  knee  followed.  Sawed  surfaces  and  liesli-wound 
united  by  primary  union.  The  nails  being  withdrawn  on  the  twelfth  day,  some  pus 
exuded  from  their  tracks,  showing  that  the  nails  had  not  been  well  disinfected.  Sev- 
eral revisions  were  required  on  account  of  unhealthy  granulations  in  the  drainage-holes. 
February  .4,  1885. — Patient  discharged,  with  firm  anchylosis  and  no  fistula. 

Case  IV. — Sussel  Baerenknopf.  aged  nine.  Osseal  tuberculosis;  several  fistuL-e ; 
subluxation.  August  26,  i555.— Total  exsection  at  Mount  Sinai  Hospital.  Nails; 
plaster  splint.  September  25th. — Change  of  dressing.  Drainage-tubes  and  nails  were 
withdrawn  ;  firm  anchylosis.     October  iOf/;.— Patient  discharged  cured. 

Case  V. — Leonard  Peters,  w-aiter,  aged  nineteen.  Synovial  tuberculosis;  no  fistula. 
August  27,  1885. — Total  exsection  at  the  German  Hospital.  September  27th. — Plaster 
splint,  dressings,  drainage-tubes,  and  nails  removed.  October  9th. — Sinuses  healed. 
October  19th. —  Discharged  cured,  with  firm  anchylosis. 

Case  VI. — Bertha  Deutsch,  aged  twelve.  Synovial  tuberculosis  of  five  weeks" 
standing.  Continuous  high  fever,  with  rapid  emaciation.  Probatory  puncture  yielded 
scanty  bloody  serum.  January  21,  1886. — Total  exsection  at  Mount  Sinai  Hospital. 
The  capsule  was  found  studded  with  innumerable  miliary  tubercles.  The  fever  disap- 
peared immediately  after  the  operation.  February  20th. — Plaster  splint  removed; 
wound  healed  by  first  intention.  March  10th. — Patient  discharged  cured,  with  firm 
anchylosis. 

Case  VII. — Lizzie  Boettger,  aged  twenty.  Osseal  tuberculosis  of  eighteen  years' 
standing;  rectangular  contraction  with  subluxation  backward.  No  fistula.  February 
12, 1886. — Total  exsection  at  the  German  Hospital.  March  10th. — Change  of  dressings ; 
.primary  union ;  three  nails  and  drainage-tubes  were  removed  AjJril  J^th. — Patient 
complained  of  a  good  deal  of  pain  in  walking.  A  hard  body  could  be  felt  under  the  skin 
on  the  outer  aspect  of  the  tibia.  An  incision  exposed  the  head  of  the  fourth  nail,  which 
had  not  been  found  at  the  first  change  of  dressings.  It  was  withdrawn  with  some 
force,  a  little  blood  exuding  from  its  track.     May  9f/^— Patient  was  discharged  cured. 

Case  VIII. — Anna  Sauer,  aged  twenty-two.  Synovial  tuberculosis  with  osseal 
ulceration  of  articular  surfaces  of  both  femur  and  tibia.  No  fistula.  May  10,  1886. — 
Total  exsection  at  the  German  Hospital.  Ju7ie  12th. — First  change  of  dressings ;  pri- 
mary union  of  soft  parts;  delayed  union  of  the  bones.  August  1st. — Discharged  cured, 
with  firm  anchylosis. 

Case  IX. — Katie  Walter,  aged  eighteen.  Synovial  tubercolosis  with  caseous  de- 
posits in  several  recesses  of  the  capsule,  notably  around  and  behind  the  crucial  liga- 
ments. Caries  of  articular  surfaces.  No  fistula.  May  18,  1886. — Total  exsection  at 
the  German  Hospital.  Slight  fever  following  the  operation,  the  dressings  were  re- 
moved May  26th.  Marginal  slough  of  the  upper  edge  of  the  skin  wound.  June  17th. — 
Nails  were  removed;  firm  anchylosis.     July  26th. — Patient  discharged  cured. 


TREATMENT  OF  TUBERCULOSIS. 


325 


Case  X. — Emma  Fi'iedmann,  aged  twenty-seven.  Synovial  tubercnlosis  with  caries 
of  articular  surfaces.  No  fistula.  April  18,  1887. — Total  exsection.  April  22d. — 
Considerable  secondary  oozing  necessitated  a  change  of  external  dressings  and  plaster 
splint.  Feverless  course.  May  23d. — Change  of  dressings ;  primary  union ;  firm 
anchylosis.  Tubes  and  three  nails  were  removed ;  a  fourth  nail  could  not  be  found, 
but  was  removed  by  incision  on  June  2d.  Patient  was  discharged  cured,  with  firm 
anchylosis,  July  1st. 

Case  XL — Hilda  Mildenbach,  aged  thirty-two.  Octoier  25,  1887. — Total  excision 
at  Mount  Sinai  Hospital.     Discharged  cured,  January  19,  1888. 

Case  XII. — Ernst  Marquandt,  musician,  aged  thirty-three.  Tuberculosis  of  left 
testicle  and  right  knee-joint,  with  fistula  and  closed  abscess  of  calf.  March  20,  1888. 
— Castration  at  Mount  Sinai  Hospital.  April  27th. — Excision  of  knee.  Discharged 
cured.  June  21^,  1888. — The  patient,  who  also  suffered  from  a  chronic  lung  affection, 
presented  himself,  in  April,  1890,  to  the  author,  in  a  most  fiourishing  state  of  health. 

Case  XIII. — Solomon  Weil,  butcher,  aged  fifty.  Excision  of  knee  for  tuberculosis 
and  subluxation  of  forty-eight  years'  standing,  November  9,  1888,  at  Mount  Sinai 
Hospital.     Discharged  cured,  December  23,  1888. 

Case  XIV. — Herman  Guentner,  engraver,  aged  twenty-two.  Excision  of  knee, 
February  8,  1889,  at  the  German  Hospital.     Discharged  cured,  April  28,  1889. 

Case  XV. — Nicolas  Straub,  stableman,  aged  fifty-six.  Excision  of  knee,  February 
19,  1889,  at  the  German  Hospital.     Discharged  cured,  April  13,  1889. 

Case  XVL — William  Weinert,  cigarmaker,  aged  forty.  Excision  of  knee,  February 
22,  1889,  at  Mount  Sinai  Hospital.     Discharged  cured,  April  5,  1889. 

Case  XVII. — Solomon  Chabelsky,  tailor,  aged  twenty-seven.  Excision  of  knee, 
April  25,  1889,  at  Mount  Sinai  Hospital.     Discharged  cured,  June  16,  1889. 

Case  XVIIl. — Mamie  Simon,  school-girl,  aged  thirteen.  Anchylosis  of  tuberculous 
knee-joint  in  subluxation  and  flexion  at  right  angle.  Excision,  November  8,  1889.— 
Discharged  cured,  December  16,  1889. 

Note. — To  prevent  the  disagreeable  necessity  of  cutting  down  for  searching  out  a  nail  buried 
in  the  tissues,  Dr.  F.  Lange's  suggestion  of  fastening  a  silk  ligature  to  the  head  of  each  nail  be- 
fore driving  it  in  seems  to  be  very  appropriate. 

/.  Ai;rKLE  AND  Foot. — Tuberculous  affections  of  the  ankle-joint,  or  of 
the  joints  formed  by  the  tarsal  and  meta- 
tars?,l  bones,  require,  in  case  of  the  pres- 
ence of  one  or  more  sinuses,  exsection  of 
the  diseased  parts.  The  long-continued 
discharges  and  lack  of  active  exercise  are 
very  apt  to  reduce  the  general  condition 
of  the  patient  to  serious  angemia  and 
marasm,  and,  the  disease  extending  to 
most  of  the  complicated  structures  of  the 
foot,  may  finally  require  amputation. 

Early  operations,  especially  in  chil- 
dren, yield  good  functional  results,  as  the 
extent  of  the  removal  can  be  limited  to 
the  parts  actually  involved. 

Exsections  of  the  ankle  or  of  other  joints  of  the  foot  are  not  followed 
by  good  results  in  grown  subjects,  on  account  of  the  technical  difficulty 


Fig.  229.— Arraneemeut  of  patient  for 
Mikulicz's  operation. 


326 


RULES  OF   ASEPTIC   AND  ANTISEPTIC  SURGERY. 


of 
cul 


a  complete  removal  of  the  synovial  membrane.     Relapse  of  the  tuber- 
ar  process  often  supervenes,  making  amputation  a  necessity. 

In  tuberculosis  of  the  calcaneiim  or  the  astragalo- 
calcaneal  joint,  Mikulicz's  osteoplastic  exsection  of  the 
tarsus  deserves  employment.  The  lov/er  ends  of  the 
tibia  and  tibula  are  sawed  off  as  in  Syme's  amputation, 
and  the  articular  surfaces  of  the  cuboid  and  scaphoid 
bones  are  also  sawed  off,  so  as  to  fit  the  section  of  the 
tibia  and  fibula.  (Fig.  230.)  Nutrition  of  the  anterior 
part  of  tlie  foot  is  maintained  by  the  dorsalis  pedis 
artery,  and  the  patient  soon  learns  to  walk  on  the  balls 
of  the  toes,  as  in  pes  equinus. 
(Fig.  231.) 

Case.  —  Hermann    Mehle,     barber, 
aged  thirty-four.      Synovial  tuberculo- 
sis of  the  astragalo-calcaneal  joint,  with 
several  fistula  situated  to  the  right  and 
left  of  the  tendo  Acbillis.     August  20, 
1885. — Osteoplastic  exsection  of  tarsus 
at  the  German  Hospital.    Primary  union 
of  the  deep  parts  of  the  wound  and  of  the  bones.     Marginal  sloughing  of  limited 
extent  of  the  upper  edge  of  the  wound  delayed  the  cure  somewhat.     October  10th. — 
Patient  was  discharged  cured. 


Fig.  230. — Diagram  illustrating  the  plan  of 
Mikulicz"  s  operation.     ( Esmareh. ) 


Note. — This  operation  was  emplo_ved  by  the  author  successfully  in 
two  more  cases.  In  one,  an  epithelioma  of  the  calcaneal  region ;  in 
the  other,  extensive  chronic  ulceration,  due  to  frost-bite  of  the  heel, 
was  the  indication  to  its  performance. 

The  preparation  of  the  foot  to  be  operated  on  is  of 
very  great  importance,  and  thorough  removal  of  effete 
epidermis  and  dirt  is  a  necessary  condition  of  asepti- 
cism  (see  page  64).  In  exsection  of  the  ankle,  the 
bilateral  incision  gives  very  good  access  to  the  ankle- 
joint,  though  excision  of  the  capsule  will  be  found,  at 
best,  difficult  to  accomplish. 

It  being  desirable  to  produce  a  movable  joint,  sub- 
periosteal dissection  is  to  be  aimed  at,  as  in  exsection 
of  the  elbow.  As  soon  as  the  sinuses  are  healed,  active 
use  of  the  foot  on  crutches,  aided  by  a  shoe  and  brace, 
or  a  silicate-of-soda  splint,  should  be  encouraged.  The 
tendency  to  posterior  or  lateral  deviation  of  the  foot 
will  be  best  met  by  the  long-continued  use  of  a  sup- 
porting apparatus  of  one  kind  or  another. 

Case  I. — Caecilia  Raab,  aged  twenty-two.     Synovial  tuber- 
culosis of  ankle-joint  with  several  sinuses.     Xotemler  9,  1882.  Fig- 231-— Shape  of  foot 
•*                                                                                 '  after  Mikulicz's  oper- 
— Exsection  of  ankle-joint  at  the  German  Hospital.     Healing        ation.    (Esmarch.) 


TREATMENT  OF  TUBERCULOSIS.  32Y 

of  the  wound  progressed  favorably,  when,  November  30th,  the  patient  contracted 
acute  lobar  pneumonia,  in  consequence  of  which  she  died  December  2,  1882. 

Case  II. — George  Eitt,  aged  six.  Tuberculosis  of  ankle-joint  caused  by  a  cheesy 
focus  in  the  astragalus.  January  11^  1883. — Partial  exsection  of  ankle-joint,  part  of 
the  astragalus  and  the  malleoli  being  removed.  March  13th. — Scraping  of  the  sinuses 
on  account  of  relapsing  tuberculosis.  Sinuses  persisted  until  the  summer  of  1884 
when  Dr.  F.  Lange,  then  on  duty  at  the  German  Hospital,  performed  total  exsection 
which  resulted  in  a  cure  of  the  tuberculosis,  but  with  pseudarthrosis.  July  20.,  1885. 
— The  author  exsected  the  ligamentous  mass  interposed  between  the  lower  aspect  of 
the  tibia  and  fibula  and  the  calcaneum,  and  fixed  the  latter  to  the  tibia  by  a  steel  nail 
driven  through  from  the  planta  pedis.  Primary  adhesion  followed,  with  the  formation 
of  a  slightly  movable  union  of  the  tibia  and  calcaneum.  September  5th. — The  boy  was 
discharged  cured.     In  January,  1886,  the  brace  worn  until  then  was  dispensed  with. 

Case  III. — Henry  Holzfaller,  aged  four.  Osseal  tuberculosis  of  ankle-joint.  March 
SO,  1883. — Total  exsection  at  the  German  Hospital.  May  25th. — Patient  discharged 
cured  with  serviceable  joint. 

Case  TV. — -Frida  Schmoltz,  aged  three  and  a  half,  Osseal  tuberculosis  of  ankle- 
joint  with  fistida.  September  19,  1883. — Removal  of  external  malleolus  and  part  of 
astragalus,  which  contained  a  caseous  deposit.  October  15th. — Wound  completely 
healed.  Plaster-of-Paris  splint  applied.  October  31st. — Silicate-of-soda  splint  applied, 
and  patient  directed  to  use  the  foot.  August  4,  1885. — Normal  position  of  foot ;  func- 
tion perfectly  re-established. 

Case  V. — I.  S.,  aged  eight.  Osseal  tuberculosis  of  ankle-joint  with  three  sinuses. 
September  26,  1883. — Partial  exsection  of  ankle-joint;  astragalus  and  inner  malleolus 
were  removed.  November  15th. — Patient  discharged  cured,  with  improving  function 
and  normal  position  of  the  foot. 

Case  VI. — Jacob  Deibel,  farmer,  aged  twenty-three.  Synovial  tuberculosis  of 
ankle  and  of  astragalo-calcaneal  joints.  March  12,  1886. — Removal  of  both  malleoli 
and  of  entire  astragalus  at  the  German  Hospital.  April  20th. — Patient  discharged 
cured,  with  fair  function  of  the  foot,  walking  with  the  aid  of  a  stick. 

Case  VII. — Abraham  Moses  Goldenberg,  aged  four.  Osseal  tuberculosis  of  ankle- 
joint  and  sinuses.  November  8,  1886. — Total  exsection.  Several  relapses  required  re- 
peated scraping  with  a  sharp  spoon.    June  3,  1887. — The  patient  was  discharged  cured. 

Case  VIII. — Lizzie  Holzhauer,  aged  fourteen.  Osseal  tuberculosis  of  ankle-joint 
with  sinus.  Excision  of  astragalus,  March  16,  1889,  at  the  German  Hospital.  Dis- 
charged cured,  June  5,  1889. 

Case  IX. — Mollie  Marks,  aged  two.  Very  far-gone  osseal  tuberculosis  of  ankle- 
joint.  Total  excision  at  the  German  Hospital,  October  27,  1887.  Discharged  cured, 
December  18,  1887. 


PART    IV. 

GONOREHCE  A : 
ITS    ANTISEPTIC    TREATMENT. 


CHAPTEE  IX. 


NATURAL  HISTORY  AND    TREATMENT  OF  QONORRHCEA. 
I.     ETIOLOGY    OF    GONORRHCEA.      GONOCOCCUS. 


Fig.  232. 
Pure    culture    of 
ffonococcus  (700 
diameters). 
(From  Bumm.) 


In"  examining  the  purulent  secretion  produced  by  a  virulent  case  of  ure- 
thral gonorrhoea,  the  observer  will  detect  with  the  microscope  a  number  of 
dark,  round  objects  resembling  grains  of  fine  gunpowder,  that  are  vividly 
oscillating,  and  can  be  clearly  distinguished  from  the  adja- 
cent pus-corpuscles.  The  use  of  a  stronger  lens  will  reveal 
the  fact  that  each  individual  coccus  is  divided  in  two  un- 
equal halves.  If  staining  is  em23loyed,  the  body  of  the  coc- 
cus will  aj^pear  colored,  and  the  dividing-line  will  become 
very  conspicuous  in  the  shape  of  a  light,  colorless  streak. 
(Fig.  233.) 

Frequently  an  indication  of  incipient  secondary  division  of  each  half  of 
the  coccus  can  be  seen.    Thus  four  cocci  will  be  united  to  a  seemingly  single 
body,  which  can  be  aptly  compared  with  four  coherent  biscuits,  divided  into 
equal  quarters  by  two  cross -shaped 

#@)  ®  ^  ^     grooves.  M^...-, 

Tlie  favorite  location  of  the  gono- 
cocci  found  in  the  urethral  secretions 
is  luitliin  the  pus-corjmscles.  This 
peculiarity  belongs  exclusively  to  the 
coccus  of  gonorrhoea  detected  by  Neis- 
ser  in  1879,  and  represents  its  most  important  charac- 
teristic.    (Fig.  234.) 

Gonococci  are  to  le  found  in  the  secretion  of  every 
case  of  gonorrhoea,  provided  that  no  germicidal  injec- 
tions were  used. 

Infection  of  the  urethra  with  pus  containing  gono- 
cocci aliuays  produces  gonorrhoea,  and  secretions  that  do 
not  contain  gonococci  are  invariably  non-infectious  if 
brought  upon  the  urethral  mucous  membrane. 

Gonococci  have  a  peculiarly  invasive  faculty,  by  which  they  penetrate 
first  the  superficial  layers  of  the  epithelial  membrane,  and  gradually  by 
further  proliferation  the  submucous  layer.     (Fig.  236).    The  route  of  their 

44 


Fig.  233. 
Development    and 
fission   of  gono- 
coccus.       (From 
Bumm.) 


\ 


Fig.  234.  —  Epithelial 
cell  studded  ■with 
fi-onococci ;  pus  cell, 
Its  protoplasm  filled 
with  gonococci ;  an- 
other pus  ceU  gorged 
with  gonococci  ;  a 
group  of  free  cocci 
alongside  of  a  nor- 
mal pus  -  cell  (700 
diameters).  (From 
Bumm.) 


332  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

inroads  is  along  the  intercellular  substance.  An  intense  hyperaemia  of  the 
capillaries  and  other  blood-vessels  adjoining  the  seat  of  the  primary  infec- 
tion leads  to  a  massive  emigration  of  white  blood-corpuscles  into  the  affected 
epithelium.    This  and  the  growth  of  the  gonococcal  colonies  lead  to  a  rapid 

disintegration  of  the  epithelium,  which  is 
^^>  A  ^"^^  washed  away  by  the  lymph-serum  in  the 


_  _  y^_^      *Af        ^^  ^^•^*i^  shape  of  single  cells  or  in  coherent  epi- 

^£^'«i^^>o  '^Jf&l  ce^  thelial  flakes.     Loss  of  the  epithelial  in- 

%{^.^'Vb^  ^"q  ^    *  vestment  is  often  followed  by  the  exuda- 

v5  <«%     £  f  (;  |.JQj^   Qf   jj  croupous   membrane,    beneath 

Fig.  235. — Vertical  section  through  mu-  i  •   i       i  £  ■  1.1 

ecus  membrane,  showing  first  coioiii-     which  clumps  of  gonococci  are  to  be  sccn 
zation  of  jronococci  (700  diameters),     ^j^  proccss  of  activc  proliferation.     Gono- 

(trom  Bumm.)  ^  '■ 

cocci  can  be  found  occupying  at  this 
stage  the  interstices  of  the  subepithelial  tissues,  their  columns  extend- 
ing inward  along  the  lymphatics,  whence,  according  to  various  authors 
(Kammerer),  they  may  be  transported  to  the  endocardium,  the  joints,  and 
the  synovial  sheaths  of  tendons. 

With  the  deeper  invasion  by  the  gonococci  goes  pari  passu  the  dense 
infiltration  of  the  in- 
fected   tissues    with    ,_  .       ,  _  t/^  —  ,       -       ■  ■  -       -  ^  -^ss 
leucocytes,    the    ex-      :'-"  .-f  '  %=      v=/    .        ':       -  ^A, 
tent  of  which  serves      ^=^v,    '-'  -           T'-'^n  ■  '        -'  •       .    ^t^J 
as  a  gauge  oi  the  m-             fg:  ^^  y  -  ,,,   ,-.«,  -;-;  i-"-/-  ->r-^i^'^"^K  ;--^:--  ,-•■-,•..,, 
tensitv  of  the  mfec-              ifm/f  /i'^^^w^ 3  ^-i^"^^is.  P  -  ^4.  iJ/'S^'aa 


tious  process.  ^M^   ^  ^^^^  §)fi   ^  I  f  ^^  ' 

At   the  acme   of  %  ^ 

.,  ,  Fig.  236. — Invasion  of  epithelium  by  gonococci  (TOO  diameters). 

the  process,  general-  (From  Bumm.) 

ly  reached  about  the 

end  of  the  second  or  third  week,  a  regeneration  of  the  lost  epithelial  layer 
commences.  Complete  restitution  of  the  epithelium  signalizes  the  termina- 
tion of  the  malady,  which,  however,  is  attained  only  in  favorable  cases  under 
favorable  conditions.  Generally  primarily  unaffected  parts  of  the  mucous 
membrane  become  involved  by  spontaneous  extension  of  the  infective  pro- 
cess, or  by  the  improper  use 
^  ^^i;  X  *^^.. _  of   instruments;   or  portions 

"  ■    '     •       '  ■' -  -      ••••"•"-■     •    — ■    -  ■    which    have    recovered    suc- 


.-  4/, 


'J_/.  U'    x^--^'  ^/  -  -'^  cnmb  anew  to  gonococcal  de- 

'Q'^lf  r^S^  .-^  struction. 
^i^cc'^  "'^'^/"Iv*^  "^^^^    regeneration   of  the 

<S  «D  **|)    **  epithelium  is  always  accom- 

FiG.  237.— Proliferation  of  gonococci  in  the  epithelium       ^„„iof1    hv  hvnpmlnsin     whiph 

(700  diameters).    (From  Bumm.)  pauiett  Dy  nyperpiasia,  Av  nicn 

somewhat  resembles  by  its 
tubular  formations  epitheliomatous  mucous  membrane  (Bumm).  These  foci 
of  epithelial  hyperplasia  are  often  coincident  with  the  seat  of  the  most  intense 
primary  affection.  They  also  correspond  with  those  parts  of  the  submucous 
layer  at  which  the  most  intense  inflammatory  infiltration  was  present. 


TREATMENT  OF  GONORRHCEA.  333 

As  regeneration  progresses,  the  hyperplasia  of  the  mucous  membrane 
and  the  infiltration  of  the  submucous  connective  tissue  disappear  by  absorp- 
tion. In  some  cases,  however,  cicatricial  transformation  of  the  neiu-formed 
connective  tissue  of  the  submucous  layer  tahes  place  instead  of  adsorption, 
and  organic  stricture  develops. 

The  transient  hyperplastic  conditions  existing  immediately  after  the 
termination  of  the  gonorrheal  process,  and  which  generally  give  rise  to  a 
scanty  secretion  called  gleet,  are  mistahenly  called  strictures  hy  various 
authors. 

In  contradistinction  to  stricture,  which  is  a  permanent  condition,  they 
must  be  declared  to  be  transient  stenoses  of  the  urethral  caliber,  which  in 
most  cases  do  disappear  without  or  with  the  methodical  introduction  of  a 
full-sized  bougie  or  sound.  The  salutary  effect  of  dilatation  upon  these 
coarctations  of  the  epithelial  and  submucous  layers  is  explained  by  the 
hastening  of  the  absorption  of  the  cellular  infiltration  by  pressure. 

It  is  true  that,  if  neglected,  some  of  these  coarctations  will  not  be  ab- 
sorbed, but  will  become  veritable  cicatricial  strictures.  Nevertheless,  it  is 
an  error  to  declare  each  and  every  narrowi7ig  of  the  urethral  caliler  observed 
shortly  after  a  gonorrhceal  attach  a  "stricture  of  wide  caliber."  The  term 
of  "incipient  stricture"  is  less  objectionable,  though  often  incorrect,  as 
many  of  these  "  strictures  "  disappear  spontaneously. 

Note. — The  presence  of  various  micro-organisms,  aside  from  the  gonococcus,  in  recent  and 
chronic  urethral  discharges,  seems  to  point  to  the  fact  that  most  cases  of  urethritis  represent  a 
mixed  form  of  bacterial  infection.  There  is  no  doubt  that  the  inoculation  of  pyogenic  microbes 
into  a  gonorrhoeally  affected  mucous  membrane  forms  an  important  element  determining  the 
intensity  and  perniciousness  of  some  very  bad  cases.  This  assumption  is  also  more  in  accord- 
ance with  the  theory  of  the  development  of  metastases,  notably  of  gonorrhceal  rheumatism. 
Bumm  is  very  reserved  in  regard  to  the  acceptance  of  Kammerer's  investigations,  who  found 
gonococci  in  recent  effusions  produced  during  an  attack  of  gonorrhceal  rheumatism.  On  the 
other  hand,  we  know  that  rheumatic  attacks  are  occasionally  provoked  by  an  instrumental 
examination  of  the  urethra  of  a  patient  afflicted  with  "  simple  "  or  "catarrhal  "  or  "traumatic" 
urethritis,  in  which  the  absence  of  gonococci  is  indisputable.  Finally,  the  frequent  presence  of 
simple  pyogenic  organisms  in  rheumatic  effusions  is  generally  accepted.  It  seems,  then,  that 
pus-generating  organisms  play  an  important  part  in  cases  of  gonorrhoeic  and  non  gonorrhoeic 
urethritis,  and  that  the  metastatic  processes  complicating  urethral  inflammations  are  mostly 
chargeable  to  their  and  not  to  the  presence  of  gonococci.  Hence  the  name  "  urethral  rheuma- 
tism "  would  be  preferable  to  "  gonorrhceal  rheumatism.'' 

II.     TREATMENT    OF    GONORRHCEA. 

1.  Acute  Gonorrhoea.  Clap. — For  practical  reasons  it  will  be  found 
most  convenient  to  divide  the  male  urethra  into  two  easily  distinguished 
parts. 

The  first  part  comprises  the  anterior  portion  of  the  urethra,  extending 
from  the  meatus  to  the  "cut-off  muscle,"  or  compressor  urethrce,  which  is 
situated  in  the  membranous  portion.  All  secretions  originating  in  this 
anterior  portion  of  the  urethra  will  readily  escape  by  the  meatus  into  the 
linen  of  the  patient. 


334  RULES  OF  ASEPTIC  AXD  ANTISEPTIC  SURGERY. 

The  second  or  dee})  j}ortio7i  of  the  urethra  consists  of  a  fraction  of  the 
membranous  part,  together  with  the  prostatic  portion — in  short,  of  all  that 
is  situated  behind  the  ''cut-off  muscle." 

This  posterior  portion  of  the  urethra  is  correctly  called  the  neck  of  the 
Madder,  as  it  forms  one  cavity  with  tlie  bladder  whenever  this  becomes 
distended  with  urine.  The  internal  sphincter  alone,  unable  to  resist  long, 
yields  readily  to  the  pressure  of  the  urine.  The  voluntary  contraction  of 
the  compressor  urethrse  becomes,  then,  the  only  barrier  to  the  escape  of  the 
urine,  and  water  is  voided  immediately  after  the  relaxation  of  this  muscle. 

Discharges  secreted  in  the  posterior  part  of  the  urethra  can  not  escape 
outward  past  the  compressor  muscle,  and  do  not  appear  at  the  meatus  in 
the  shape  of  an  external  discharge,  as  those  of  the  anterior  urethra.  They 
accumulate  in  the  neck  of  the  bladder,  and  are  voided  only  with  the  urine, 
which  is  rendered  somewhat  turbid  by  this  admixture. 

A  very  useful  practical  test  for  determining  the  seat  of  urethral  inflam- 
mation is  that  suggested  by  Ultzmann. 

The  patient  is  made  to  pass  his  water  consecutively  into  two  tumblers, 
so  that  the  amount  voided  should  be  about  evenly  distributed  in  the  two 
vessels.  Whenever  the  anterior  urethra  alone  is  the  seat  of  inflammation, 
only  the  first  half  of  the  urine  icill  be  turbid,  or  at  least  will  be  found  con- 
taining flakes  and  threads  ;  the  second  portion  loill  appear  perfectly  clear. 

In  cases  of  deep-seated  urethritis — that  is,  when  the  nech  of  the  bladder 
is  affected — the  first  tumbler  luill  receive  flaky  and  turbid  urine,  and  the 
water  held  by  the  second  glass  ivill  appear  also  turbid,  but  someiohat  less  so 
than  the  first  portion. 

An  additional  and  most  important  symptom  of  the  affection  of  the  neck 
of  the  bladder  \^  frequent  micturition,  in  acute  cases  accompanied  by  severe 
spasm  and  the  escape  of  a  small  quantity  of  blood  at  the  end  of  the  act. 
Simultaneously  with  the  severe  contraction  of  the  vesical  muscles,  anal 
tenesmus  is  observed. 

In  every  case  of  recent  gonorrhoea  the  infectious  process  is  confined  to 
the  anterior  urethra,  and  first  to  its  foremost  portion  alone.  It  extends 
from  the  meatus  backward  to  the  compressor  urethras,  where  it  generally 
stops.  In  exceptional  cases  only  does  it  penetrate  to  the  deep  urethra,  as 
the  "cut-off  muscle*'  seems  to  serve  as  an  effective  barrier  to  its  extension 
backward. 

Note. — Forcible  urethral  injections  made  from  a  syringe  containing  too  large  a  quantity  of 
fluid,  or  the  premature  introduction  of  a  sound,  are  frequent  causes  of  the  infection  of  the  neck 
of  the  bladder. 

The  seat  of  the  most  intense  inflammation  of  the  urethra  is  in  its  natu- 
rally widest  parts — that  is,  in  the  fossa  navicularis  and  the  sinus  bulbi.  Here 
we  find  located  the  majority  of  all  strictures. 

a.  Anterior  Gonorrhceal  Urethritis. — The  treatment  of  anterior 
gonorrhoeal  urethritis  should  be  very  discreet  in  the  first  invasive  stage  of 
the  disease.  It  should  consist  of  rest  and  appropriate  general  sedative  man- 
agement.   Locally,  cold  api^lications  will  be  found  very  grateful  and  effective. 


TREATMENT  OF  GONOREHCEA.  335 

As  soon  as  the  turbulent  first  onset  has  abated,  local  treatment  by  dis- 
infectants should  commence.  Since  the  cedematous  swelling  of  the  j^arts 
is  still  prominent,  introduction  of  any  instrument  for  the  purpose  of  irri- 
gation will  have  to  be  done  with  some  force.  It  will  cause  abrasions  of  the 
tumid  epithelium,  and  thus  will  open  new  portals  to  gonococcal  and  pyo- 
genic inyasion.     Hence  irrigation  at  this  period  is  to  be  condemned. 

Urethral  injections,  on  the  other  hand,  done  with  a  properly  shaped 
syringe  of  moderate  capacity,  are  very  useful.  Sigmund's  syringe,  hav- 
ing a  blunt  conical  nozzle,  is  an  appropriate  instrument.  It  holds  three 
eighths  of  an  ounce 
of  fluid,  which  quan- 
tity is  sufficient. 
(Fig.  238.) 

The    strength    of  Fig.  238.— Sigmund's  urethral  syringe. 

the  solutions  em- 
ployed should  also  be  determined  by  the  intensity  of  the  local  symptoms. 
Strong  solutions  will  cause  intense  smarting,  and  on  that  account  the  injec- 
tions will  not  be  made  frequently  enough  by  the  patient.  In  very  sensitive 
cases  an  entirely  unirritant  tepid  solution  of  salt  water  (6:1,000,  or  a  tea- 
spoonful  to  a  quart)  can  be  employed  with  much  benefit.  As  the  symptoms 
abate,  sulphocarbolate  of  zinc  (fifteen  grains  to  six  ounces),  or  permanganate 
of  potash  (one  grain  to  six  ounces),  can  be  substituted  for  the  saline  solution. 

The  main  object  of  these  first  injections  is  the  cleansing  of  the  urethra  ; 
hence  the  injections  must  he  made  frequently ,  at  least  six  times  in  a  day,  or 
oftener.  Each  injection  should  be  preceded  by  urination,  and  should  be 
a  double  one — the  first  syringeful  to  wash  out  the  pus  ;  the  second  syringe- 
ful  to  act  upon  the  mucous  membrane.  This  second  injection  should  be 
retained  in  the  urethra  for  two  minutes.  The  strength  of  the  injections 
should  be  increased  yj^ri  passu  with  the  abatement  in  the  acuity  of  the  local 
symptoms,  but  the  solutions  should  never  be  made  corrosive. 

Every  patient  should  receive  practical  instruction  from  the  physician 
regarding  the  proper  manner  of  injecting. 

Note. — The  author  saw  a  case  of  chronic  gonorrhoea  that  had  successively  passed  through 
the  hands  of  three  colleagues,  none  of  whom  convinced  himself  whether  the  patient  was  making 
the  injections  properly  or  not.  Phimosis  was  present,  and  the  patient  was  in  the  belief  that 
the  injections  had  to  be  made  under  the  prepuce.  Xo  wonder  his  clap  had  remained  uninflu- 
enced by  this  treatment. 

In  the  later  stages  of  acute  gonorrhoea  irrigation  of  the  anterior  urethra 
will  be  found  a  very  satisfactory  and  effective  mode  of  treatment.  It  should 
be  done  by  the  physician  himself  at  least  once  daily,  or  as  often  as  j)ossible, 
in  the  following  manner  : 

A  pint  bowl  is  filled  with  tepid  water.  To  this  is  added  enough  con- 
centrated solution  of  permanganate  of  potash  to  color  the  water  to  the  hue 
of  light  claret.  A  straight  or  slightly  beaked  female  catheter  of  metal  (Fig. 
239),  five  inches  in  length  (No.  8  English  caliber),  is  lubricated  loith  glyc- 
erin, and  is  introduced  as  far  as  the  compressor-urethrse  muscle.     When- 


a  hand-syringe  holding  four  or 
five  ounces,  and  injects  the  fluid 


336  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

ever  the  beak  of  the  instrument  comes  in  contact  with  the  muscle  this  will 
contract,  and  will  resist  further  introduction.  The  patient  stands  in  front 
of  the  sitting  physician,  and  is  made  to  hold  a  pus-basin  or  tin  pan  under 

his   scrotum   and   penis.     The 
^=^ «^— '"'^^    physician  fills  with  the  solution 

Fig.  239. — Short  metallic  catheter  for  irrigation  of  ,  in  ,i     j         •    ,       ,i 

anterior  urethra.  through  the  Catheter  mto  the 

urethra,  whence  it  will  readily 
escape  by  the  meatus  into  the  pus-basin.  This  is  repeated  until  the  solu- 
tion is  exhausted.     Irrigation  should  be  preceded  by  micturition. 

With  proper  diet  and  regime,  ordinary  cases  of  gonorrhoea  will  be  cured 
by  this  treatment  in  from  three  to  six  weeks. 

Note. — To  prevent  soiling  of  the  patient's  linen  by  profuse  urethral  discharges,  the  follow- 
ing simple  arrangement  will  be  found  eifective  and  convenient.  A  child's  sock  is  fastened  with 
a  safety-pin  to  the  interior  of  the  skirt  of  the  patient's  undershirt.  In  the  toe  of  the  sock  is 
thrust  a  small  ball  of  cotton,  which  is  then  drawn  over  the  penis,  and  is  held  there  by  the  sock. 
Whenever  occasion  permits,  the  soiled  cotton  is  replaced  by  clean  material,  and  thus  no  tell- 
tale blotches  will  be  made  on  shirt  and  drawers. 

l.  Deep-seated  Gonorrhceal  Urethritis. — Spontaneous  extension 
of  gonorrhceal  infection  beyond  the  cut-off  muscle  to  the  posterior  part  of 
the  urethra  is  a  comparatively  rare  occurrence.  More  frequently  infection 
is  carried  to  the  deep  urethra  by  too  large  injections  or  the  premature  inser- 
tion of  sounds.  As  long  as  in  a  case  of  anterior  gonorrhoea  the  discharges 
are  profuse  and  creamy,  and  the  mouth  of  the  urethra  edematous  and  red, 
no  sound  should  ever  he  passed. 

Infection  of  the  deep  urethra  invariably  provokes  an  unmistakable  com- 
plex of  symptoms — namely,  frequent  urination,  which  is  followed  at  its 
termination  by  a  violent  spasmodic  pain  and  the  escape  of  some  bloody 
urine  or  a  few  drops  of  pure  blood. 

Ordinary  injections,  or  even  irrigations  of  the  urethra  as  above  described, 
are  utterly  unable  to  reach  and  to  influence  the  course  of  deep-seated  gon- 
orrhoea. To  cleanse  and  disinfect  the  diseased  part,  an  efficient  germicidal 
solution  must  be  brought  exactly  in  contact  with  the  morbid  mucous  mem- 
brane of  the  posterior  urethra.  If  we  inject  a  solution  into  the  bladder,  its 
chemical  properties  will  be  at  once  destroyed  by  the  admixture  of  urine, 
hence  means  must  be  found  by  which  we  can  make  the  unchanged  solution 
come  in  contact  with  the  seat  of  the  disease.  For  this  purpose  Ultzmann^s 
method  of  irrigating  the  neclc  of  the  bladder  will  be  found  very  effective. 

As  soon  as  the  most  acute  invasive  stage  of  the  affection  shall  have  be- 
come mitigated  by  rest,  sedatives,  balsamics,  and  proper  diet — that  is,  in  about 
the  third  or  fourth  week — a  quart  of  a  mild,  tepid  solution  of  permanganate 
of  potash  (1  :  5,000)  is  prepared.  A  not  too  small-sized  soft  gum  (Nelaton's) 
catheter  (Fig.  240)  is  lubricated  with  glycerin,  and  is  introduced  as  far  as 
the  compressor-urethrae  muscle.  A  hand-syringe  holding  about  four  ounces 
of  fluid  is  filled  with  the  solution,  which  is  then  injected  into  the  catheter, 


TREATMENT  OF  GONORRHCEA. 


337 


and  will  be  seen  escaping  from  the  meatus  alongside  of  the  instrument. 
After  this  preliminary  washing  of  the  anterior  urethra,  the  patient  is  di- 
rected to  assume  the  recumbent  posture.  The  soft  catheter  is  again  lubri- 
cated, and  is  passed  gently  into  the  bladder.  This  process  will  be  very 
much  facilitated  by  the  injection  of  a  small  quantity  of  glycerin  through 
the  catheter  when  it  is  about  to  pass  the  cut-off  muscle.  A  small  amount 
of  pressure  will  overcome  the  tension  of  the  compressor,  and  the  arrival  of 
the  point  of  the  instrument  in  the  desired  locality  can  be  tested  by  injecting 
an  ounce  or  two  of  the  prepared  lotion.  Should  it  escape  from  the  urethra, 
this  would  be  a  sign  that  the  eye  of  the  catheter  has  not  passed  the  com- 


FiG.  240. — N^laton's  soft  gum  catheter. 

pressor  muscle.  If,  on  removal  of  the  syringe,  the  lotion  is  seen  to  escape 
at  once  from  the  bladder  through  the  catheter,  then  it  may  be  concluded 
that  the  eye  of  the  catheter  is  in  the  cavity  of  the  bladder,  and  that  it  has 
been  introduced  too  far,  and  needs  to  be  withdrawn  an  inch  or  a  little  more 
or  less.  Should,  on  renewed  injection,  the  lotion  all  enter  the  Madder,  but 
fail  to  escape  through  the  catheter,  this  is  a  positive  sign  that  the  leaJc  of 
the  instrument  is  just  beyond  the  cut-off  muscle — that  is,  in  the  posterior 
part  of  the  membranous  portion.  Fluids  injected  into  this  place  will  readily 
enter  the  bladder,  as  their  pressure  can  easily  overcome  the  internal  sphinc- 
ter ;  but  recontraction  of  this  muscle  will  prevent  their  escape  until  the 
beak  of  the  instrument  is  pushed  into  the  vesical  cavity.  According  to  the 
irritability  of  the  patient,  from  one  to  four  ounces  of  the  lotion  are  slowly 
injected  while  the  point  of  the  catheter  is  located  in  the  space  between  the 
cut-off  and  internal  sphincter  muscles.  As  soon  as  the  patient  complains 
of  pressure,  injection  should  cease,  and  the  catheter  should  be  gently  pushed 
within  the  vesical  cavity,  whence  it  will  at  once  conduct  the  injected  fluid 
into  a  vessel  placed  between  the  thighs  of  the  patient.  It  is  better  not  to 
inject  too  large  a  quantity  at  the  beginning,  as  this  is  liable  to  bring  on 
vesical  spasm,  resulting  in  a  violent  and  irresistible  expulsion  both  of  lotion 
and  catheter. 


338 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


The  injections  are  to  be  repeated  in  this  manner  until  the  lotion  is  seen 
to  return  clear  from  the  bladder.  Tlie  final  injection  is  voluntarily  passed 
by  the  patient.  This  is  to  satisfy  him  that  his  bladder  is  empty,  and  that 
the  sensation  of  the  desire  to  urinate  is  not  caused  by  retained  fluid. 

The  improvement  following  this  procedure  is  very  apparent,  though  not 
lasting,  and  daily  repetition  will  be  necessary  until  the  frequency  of  mic- 
turition will  have  been  very  materially  reduced. 

The  author  has  never  seen  any  untoward  consequences  following  this 
gentle  and  very  efficient  mode  of  treating  deep-seated  urethral  gonorrhoea. 
The  danger  of  cystitis  or  inflammation  of  the  testicle  will  be  rather  abated 
than  increased  by  this  treatment  if  it  be  carried  out  properly  and  without 
violence.  The  possibility  of  performing  the  entire  procedure  without  any 
abrasion,  undue  pressure,  or  injury  of  the  inflamed  parts,  ranks  it  high 
above  all  measures  in  which  unyielding  sounds,  catheters,  or  caustic  holders 
are  placed  in  the  neck  of  the  bladder  for  purposes  of  cauterization.  Their 
use  is  often  followed  by  epididymitis,  and  is  deservedly  held  in  bad  repute. 

Where  the  affection  extends  over  the  whole  urethra,  treatment  of  the 

neck  of  the  bladder  and  of  the  anterior  urethra  can  and  ought  to  be  carried 

out  simultaneously  until  the  secretion  escaping  from  the  meatus  be  reduced 

to  a  minimum,  and  until  the  frequent  urgency  to  urinate  and  the  turbidity 

of  the  water  give  way  to  a  marked  extent. 

Gonorrlioeal  catarrh  of  the  neck  of  the  bladder  should  not  be 
mistaken  for  acute  cystitis.     Pus  will  be  found  in  the  urine  in 


241. — Ultzaiann's  prostatic  syringe. 

both  cases,  but  in  cystitis  febrile  disturbances  accompanied  by  alteration  of 
the  general  health  will  be  observed,  and  pressure  pain  above  the  symphysis 
pubis  will  be  noted  aside  from  the  periodical  pain  located  in  the  perineal 
region,  which  follows  urination,  and  which  is  the  diagnostic  sign  of  the 

affection  of  the 
deep  urethra  only. 
Should  irriga- 
tion of  the  deep 
urethra  not  effect 
rapid  or  complete 
cessation    of    the 

affection,  instillation  of  a  fetv  drops  of  a  five-per-cent  solution  of  nitrate  of 
silver  will  be  found  very  beneficial.  This  is  done  by  Nelaton's  catheter  or 
Ultzmann's  deep  urethral  syringe.  (Figs.  241  and  242.)  The  point  of  the 
filled  instrument  is  dipped  in  glycerin,  and  is  gently  introduced  just  within 
the  compressor-urethras  muscle.  When  the  barrel  of  the  syringe  is  at  an 
angle  of  forty-five  degrees  with  the  body  of  the  recumbent  patient,  its  beak 
is  just  within  the  neck  of  the  bladder.  Three,  four,  or  five  drojis  of  the 
nitrate-of-silver  solution  are  expelled  from  the  syringe,  and  enter  the  deep 


Fig.  242. — Reyes's  modification  of  Ultzmann's  deep  urethral  syringe. 


TREATMENT  OF  GONORRHCEA. 


339 


urethra.  Intense  smarting  and  spasm  of  the  neck  of  the  bladder  follow  the 
injection,  but  soon  disappear  if  the  patient  retain  the  reclining  posture  for 
a  short  while. 

These  deep  injections  of  nitrate  of  silver  are  a  very  effective  though 
painful  means  of  checking  a  gonorrhoea!  inflammation  of  the  deep  urethra, 
and  deserve  more  frequent  employment  than  they  receive  at  present.  The 
procedure  does  not  entail  any  danger,  and  is  rather  a  preventive  than  a 
cause  of  epididymitis  or  cystitis. 

2.  Cliroiiic  Gonorrhoea.     Gleet : 

a.  IXFLAMMATORY  StENOSIS  (In'OIPIENT  StEICTURE)  AND 

Peemai^ei^t  ok  Cicateicial  Steictfee  op  the  Ueethra  : 

{a)  Anterior  Urethra. — The  termination  of  acute  gonor- 
rhoea is  never  abrupt.  It  is  always  inaugurated  by  a  period 
characterized  by  the  escape  of  a  scanty  amount  of  purulent 
discharge.  During  this  period  subacute  attacks  or  relaj)ses 
of  the  affection  may  be  precipitated  by  any  cause  inducing 
hypersemia  of  the  urethral  mucous  membrane.  Sexual  irrita- 
tion, alcoholic  indulgence,  severe  bodily  exercise,  offer  mainly 
occasions  for  this  occurrence. 

When  an  acute  gonorrhoea  has  reached  this  stage,  the  prog- 
ress of  the  recovery  often  seems  to  suffer  a  halt,  due  princi- 
pally to  secondary  hyperplastic  changes  of  the  mucous  and 
submucous  tissues.  The  daily  introduction  of  a  full-sized 
sound  or  bougie  for  a  week  or  two  is  generally  sufficient  to 
produce  rapid  absorption  of  the  interstitial  exudation  and  a 
permanent  cure. 

A  contracted  meatus  is  an  effective  impediment  to  the 
application  of  the  sound,  and  requires  an  adequate  division 
of  the  narrow  urethral  orifice.  Meatotomy,  however,  should 
never  be  carried  too  far,  its  only  object  being  the  easy  admis- 
sion of  a  full-sized  steel  sound.  It  is  made  with  a  blunt- 
pointed  tenotomy  knife,  and  the  haemorrhage  caused  by  it 
can  be  easily  checked  by  the  introduction  of  a  small  pledget 
of  iodoformed  gauze  into  the  slit. 

Should  the  patient  positively  decline  meatotomy,  blunt 
dilatation  of  the  part  of  the  urethra,  which  is  the  seat  of  the 
inflammatory  swelling  and  contraction,  can  be  done  by  Otis' s 
urethrometer.     (Fig.  243.)     The  closed  instrument  is  intro- 
duced beyond  the  coarctation,  then  it  is  opened  until  the  dial 
indicates  that  the  bulb  has  been  dilated  to  full  caliber,  and 
then  it  is  drawn  with  some  force  through  the  narrowed  portion  of  the 
urethra.     The  author  has  seen  very  good  results  follow  this  use  of  Otis's 
instrument,  though  the  procedure  does  not  deserve  preference  over  mea- 
totomy and  dilatation  by  the  steel  sound. 

The  absorption  and  disappearance  of  these  ''incipient  strictures"  is  very 
much  hastened  by  the  local  application  of  a  strong  (five-per-cent)  solution 

45 


340  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

of  nitrate  of  silver.     To  enahle  an  exact  application  of  th«  caustic  under  the 
gniclance  of  the  eye,  the  endoscope  must  he  used. 

The  endoscope  is  a  cylindrical  silver  tube  of  from  four  to  six  inches  in 
length,  and  of  various  calibers.  (Fig.  244.)  An  obturator  facilitates  its 
painless  introduction,  and  a  flange  or  shield  made  of  hard  rubber,  having  a 
"dead  finish,"  permits  an  easy  handling  of  the  instrument.  Strong  arti- 
ficial light  or  sunlight  is  needed  for  endoscopy.  The  patient  reclines  on  a 
tall  chair,  or  sits  on  the  edge  of  a  table,  his  back  supported  by  a  suitable 
rest,  the  examiner  occupying  the  space  between  the  patient's  legs.  To  pro- 
tect the  patient's  clothing  against  soiling  with  blood  or  chemicals,  a  piece 
of  rubber  cloth  (eighteen  inches  square),  provided  with  a  small  central  slit 
Just  long  enough  to  permit  the  slipping  through  of  the  penis,  is  spread  on 
the  pubic  region.    Thus  the  only  object  exposed  to  view  will  be  the  patient's 


Fig.  244. — Klotz's  urethral  endoscope.  ^^m 

penis.  Over  the  rubber  cloth  a  clean  towel  is  laid  for  wiping  off  fingers, 
etc.  A  basin  containing  a  number  of  slender  match-sticks,  their  ends 
armed  with  tufts  of  absorbent  cotton,  is  at  hand,  and  a  pus-basin  is  next  to 
it,  to  receive  the  soiled  sticks.  On  a  little  table  adjoining  the  operating- 
chair  are  a  small,  wide-mouthed  bottle  of  glycerin  and  a  few  glass  salt- 
cellars or  hour-glasses  for  the  reception  of  such  solutions  as  may  be  required. 
Of  these  the  author  uses  two — a  five-per-cent  solution  of  nitrate  of  silver 
and  a  ten-per-cent  solution  of  the  same  substance,  both  in  dark  bottles. 

An  endoscopic  tube  of  suitable  size  being  selected,  it  is  lubricated  with 
a  little  glycerin,  and  is  introduced  well  into  the  bulbous  portion  of  the  ure- 
thra. The  obturator  is  withdrawn,  and  the  surgeon  by  his  head-mirror 
directs  a  ray  of  sun-  or  lamp-light  into  the  bottom  of  the  tube,  where  the 
mucous  membrane  of  the  urethra  is  visible  in  the  shape  of  a  typical  image, 
consisting  of  several  concentric  folds  uniting  to  a  central,  funnel-shaped 
depression. 

In  sunlight  the  normal  mucous  memhrane  is  pale,  of  about  the  same  hue 
as  the  normal  buccal  lining,  and  on  it  are  visible  a  number  of  delicate  trac- 
ings, produced  by  minute  vessels.  It  is  very  smooth  and  glossy,  and  the 
folds  of  the  image  are  flexible  and  rather  delicate,  and  present  no  change  of 
color  on  deej^er  introduction  or  ivithdrawal  of  the  tube. 

Inflamed  urethrce  show  an  entirely  different  aspect.  The  most  delicate 
manner  of  introducing  the  instrument  is  apt  to  cause  slight  haemorrhage, 
which  sometimes  is  very  troublesome,  as  the  blood  fills  up  the  tube  faster 
than  it  can  be  mopped  away,  frustrating  for  the  time  being  all  further 
manipulation.  When  the  mucous  membrane,  exposed  in  the  bottom  of  the 
endoscope,  is  dried  off  with  a  pledget  of  cotton,  it  has  a  dull,  dead  gloss. 


TREATMENT  OF  GONORRHCEA.  341 

or  velvety  appearance ;  it  shows  a  more  or  less  intense,  uniform  shade  of 
red,  scarlet,  or  purple.  The  folds  of  the  endoscopic  image  are  few  and 
coarse,  and  not  so  flexible  as  those  of  the  normal  urethra. 

Gradually  withdrawing  the  tube  with  short  stops,  the  entire  length  of 
the  urethra  can  be  thus  inspected. 

In  chronic  gonorrhoeal  urethritis  the  inflammation  will  be  found  limited 
to  more  or  less  well-circumscribed  portions  of  the  urethra.  These  parts, 
examined  by  urethrometer  or  bulbous  bougie,  quite  frequently  show  a  well- 
marked  though  moderate  contraction,  which  can  also  be  demonstrated  to 
the  eye  through  the  endoscope. 

In  withdrawing  the  tube,  new  parts  of  either  normal  or  uniformly  red, 
inflamed  mucous  membrane  will  present  themselves  to  the  examiner's  eye. 
Suddenly,  however,  the  field  of  vision  will  become  pale,  perfectly  ancemic, 
and  ivory -colored.     This  change  of  color  is 
due  to  depletion  of  blood  and  the  anaemia  of 
the  constricted  part  of  the  urethra,  caused 
by  the  distention  produced  by  the  dilating     p^^  245.-MetaiUc  buib^^^H^ugie. 
instrument.    As  soon  as  the  end  of  the  tube 

is  withdrawn  from  the  stenosed  part,  the  formerly  bloodless  tissues  are  seen 
to  suddenly  flush  up  and  become  of  exactly  the  same  color  as  the  rest  of  the 
inflamed  mucous  membrane.  Examination  by  the  bulbous  bougie  (Fig.  245) 
will  show  that  the  seat  of  this  phenomenon  corresponds  exactly  with  the 
locality  of  the  narrowing  of  the  urethral  caliber. 

In  cases  where  gleet  has  persisted  for  several  months,  these  constricted 
places  appear  in  the  endoscope  of  a  pearly  color,  which  is  due  to  the  con- 
siderable thickening  of  the  epithelial  layer. 

The  application  of  the  nitrate-of-silver  solution  to  these  ''incipient  strict- 
ures "  will  be  found  to  materially  hasten  their  absorption,  if  it  be  supple- 
mented by  the  introduction  of  a  full-sized  sound.  The  applications  are 
made  through  the  endoscope  every  other  day  with  a  camel's-hair  brush  or  a 
wad  of  absorbent  cotton  fastened  to  the  end  of  a  long  match-stick.  They 
cause  a  slight  smarting,  which  does  not  persist  very  long.  Occasionally 
they  are  followed  by  slight  hsemorrhage  on  the  day  subsequent  to  the  appli- 
cation, which,  however,  is  without  any  significance. 

Most  of  these  "incipient  strictures"  get  well  under  the  treatment  just 
described,  and  do  not  require  urethrotomy. 

But,  when  the  embryonic  connective  tissue  of  these  stenoses  of  inflam- 
matory character  becomes  definitely  transformed  into  fibrillar  connective 
tissue — that  is,  a  fully  developed  cicatrix — it  represents  a  permanent — that 
is,  organic — stricture  that  can  not  be  cured  by  simple  dilatation  and  topical 
applications.  True,  it  may  be  gradually  dilated  to  the  normal  caliber,  but 
the  dilatation  will  be  evanescent,  and  speedy  recontraction  will  follow  the 
cessation  of  the  treatment. 

The  appearance  of  a  cicatricial  or  permanent  stricture  in  the  endoscopic 
field  of  vision  differs  in  many  ways  from  that  of  an  inflammatory  stenosis. 
This  diagnostic  distinction  is  all  the  more  valuable,  as  an  examination  by 


342  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

the  bulbous  bougie,  although  capable  of  demonstrating  the  presence  of  a 
narrowing  of  the  urethral  caliber,  does  not  divulge  anything  regarding  the 
nature  of  the  stenosis. 

The  most  characteristic  feature  of  permanent  strictures  is  the  unchang- 
ing anaemic,  pale  condition  of  the  mucous  membrane  about  the  stricture 
in  the  endoscopic  field  of  vision.  The  sudden  jlusliing  up  on  withdrawal 
of  the  endoscopic  tube,  seen  in  the  contractions  of  recent  date,  is  absent. 
The  second  characteristic  is  the  peculiar  rigidity  of  the  iirethral  ivall  at 
the  site  of  the  stricture.  On  withdrawing  the  endoscope,  the  rigid  walls 
of  the  urethra  show  a  tendency  to  remain  patulous,  so  that,  instead  of  a 
small  and  rapidly  changing  image  of  soft,  pliable  mucous  membrane,  a 
comparatively  long  stretch  of  the  urethra  can  be  looked  over  at  a  glance, 
resembling  somewhat  the  walls  of  a  short  tunnel. 

Absorption  and  disappearance  of  a  cicatricial  stricture  are  a  very  excep- 
tional occurrence,  whether  it  be  subjected  to  treatment  or  not.  To  suffi- 
ciently widen  a  strictured  urethra,  urethrotomy,  followed  by  methodical 
dilatation,  is  required. 

Such  a  cure  as  is  not  infrequently  observed  to  come  from  treatment  of 
an  inflammatory  stenosis — that  is,  a  perfect  restitutiofi  of  the  normal  state 
of  affairs — is  never  to  be  expected  after  the  treatment  of  a  cicatricial  stricture, 
be  this  treatment  dilatation  alone,  or  cutting  combined  with  suhsequent  dila- 
tation. The  cicatricial  ring  will  become  wider  than  before,  but  its  rigidity 
and  unnatural  appearance  will  remain  unchanged. 

The  cases  in  which  the  cicatricial  bands  can  be  divided  in  their  entirety 
yield  the  comparatively  best  results.  But  the  worst  strictures  involve  the 
entire  thickness  of  the  spongy  part  of  the  urethra,  and  to  effect  complete 
division  in  these  cases  the  entire  thickness  of  the  urethra  would  have  to  be 
cut  through,  which  is  an  impracticable  and  sometimes  dangerous  procedure. 

Case. — M.  F.,  aged  forty-two,  had  a  series  of  old  cicatricial  strictures  involving  the 
entire  anterior  portion  of  the  urethra.  One  seated  in  the  fossa  navicularis  was  very 
tight,  another  one  at  the  bulbo-merahranous  junction  was  very  massive,  so  that  it 
could  be  felt  through  the  perina;ura.  Blunt  dilatation  with  steel  sounds,  up  to  No.  34 
of  the  French  scale,  always  produced  cessation  of  the  profuse  discharge,  but,  recontrac- 
tion  to  the  old  condition  always  following  within  forty-eight  hours,  internal  ure- 
throtomy was  decided  on.  August  20, 1885. — The  operation  was  performed  with  Otis's 
urethrotome.  The  urethra  was  dilated  to  No.  30,  and  then  two  parallel  incisions  were 
made  along  the  entire  length  of  the  roof  of  the  pendulous  portion.  Some  hesitation 
of  the  bulbous  bougie  was  noted  at  the  bulbo-membranous  junction,  therefore  Otis's 
instrument  was  reintroduced,  dilated  to  No.  32,  and  the  still  narrow  part  of  the  urethra 
once  more  cut.  Smart  haemorrhage  was  observed,  but  not  more  than  the  length  of 
the  incision  justified,  and  after  some  compression  it  ceased.  On  returning  to  the  pa- 
tient after  the  lapse  of  two  hours,  the  writer  found  him  lying  on  his  blood-soaked 
mattress  in  a  pool  of  blood,  in  a  most  deplorable  state  of  prostration  and  anxiety.  The 
scrotum  and  penis  were  swollen  out  of  proportion,  and  had  assumed  a  blue-black  color, 
and  blood  was  issuing  from  the  meatus  at  varying  intervals.  A  large  English  web- 
catheter  was  introduced  and  tied  into  the  bladder,  and  only  persistent  digital  pressure 
exerted  over  the  bulbous  portion  for  more  than  two  hours  succeeded  in  arresting  the 


TEEATMENT   OF  GONOREHGEA. 


343 


loss  of  blood,  and  checked  further  bloody  infiltration  of  the  penile  and  scrotal  tissues. 
Fortunately,  infection  of  the  wound  was  avoided  by  careful  asepsis,  and.  thus,  no  fever 
and  inflammation  following,  the  entire  enormous  extravasation  was  readily  absorbed. 
Introduction  of  large  sounds  was  commenced  on  the  twelfth  day,  and  after  a  some- 
what prolonged  convalescence  the  patient  recovered.  With  the  regular  use  of  the  full- 
sized  steel  sound,  and  an  occasional  irrigation  of  the  neck  of  the  bladder,  the  patient 
succeeds  in  maintaining  a  very  comfortable  state  of  health. 

In  the  case  just  related,  complete  division  of  the  posterior  stricture 
situated  at  the  bulbo-membranous  junction,  led  to  the  injury  of  the  bulbar 
artery,  imbedded  in  the  cicatricial  mass  consti- 
tuting the  stricture.  Had  the  wound  been  in- 
fected by  the  use  of  uncleanly  instruments,  sup- 
puration and  decomposition  of  the  large  bloody 
infiltration  might  have  brought  the  jDatient  into 
Tery  great  danger. 

A  serious  objection  to  Otis's  otherwise  excel- 
lent urethrotome  is  the  great  difficulty  of  thor- 
oughly cleansing  the  complicated  instrument. 

The  Author's  Aseptic  Urethrotome  (Fig. 
246,  a)  is  simple  in  construction,  thoroughly  reli- 
able and  firm  ;  it  is  precise  in  action,  and,  being 
self-registering,  obviates  the  necessity  for  a  ure- 
thrometer,  the  functions  of  which  are  performed 
by  the  cutting  instrument  itself.  It  is  comj)osed 
of  five  easily  detachable  parts,  three  steel  rods 
and  two  screws.  One  of  the  rods  is  provided  with 
a  laterally  grooved  bulb  of  small  size  (b),  acting 
as  a  wedge,  which,  by  the  aid  of  a  stout  thumb- 
screw, serves  to  spring  apart  a  pair  of  congruent 
steel  blades  (c).  The  amount  of  separation  of 
these  steel  blades  (somewhat  resembling  a  pair  of 
old-fashioned  draper's  shears),  reduced  to  milli- 
metres, corresponding  to  the  urethral  caliber,  is 
indicated  by  a  dial  placed  above  the  ring  that 
serves  for  the  fixation  of  the  instrument.  The 
correct  adjustment  of  the  thumb-screw  is  secured 
by  a  small  check-screw  which  represents  the  prox- 
imal end  of  the  urethrotome.  The  third  rod,  a 
small  knife,  hidden  in  the  slightly  curved  beak 
of  the  instrument,  can  be  withdrawn  so  as  to  cor- 
respond to  the  place  of  widest  separation  of  the 
shear-blades.  The  caliber  of  the  closed  instru- 
ment is  exactly  fifteen  millimetres.  It  permits  of  a  distention  to  forty-five 
millimetres,  and  in  these  particulars  coincides  with  the  minimal  and  maxi- 
mal dimensions  of  Otis's  urethrotome.  It  can  be  taken  apart  in  fifteen 
seconds,  and  can  be  put  together  in  about  double  that  time. 


344 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


The  modus  operandi  is  as  follows  :  The  urethra  being  properly  prepared^ 
the  closed  instrument  is  lubricated  with  glycerin,  and  passed  in  well  beyond 
the  stricture  or  strictures.  After  this  the  shear-blades  are  separated  by 
means  of  the  thumb-screw  to  the  desired  caliber,  and  the  instrument  is. 
drawn  forward  until  it  becomes  arrested  by  the  resistance  of  the  stricture, 
Now  the  hidden  knife  is  drawn  into  position,  and  the  whole  instrument, 
being  firmly  grasped,  is  steadily  pulled  forward.  Thus  the  stricture  is 
gradually  dilated  so  as  to  offer  a  favorable  degree  of  tension  for  the  effective 
use  of  the  knife,  which  will  readily  cut  all  the  re- 

fsistent  tissues  composing  the  stricture.  The  mo- 
ment that  the  stricture  is  cut  along  its  entire  linear 
extent,  and  to  the  proper  depth,  the  distended  part 
of  the  instrument,  which  serves  the  purpose  of  a 
bulb,  will  slide  through  the  site  of  the  stricture, 
thus  indicating  that  an  adequate  amount  of  division 
has  been  accomplished.  A  series  of  strictures  can 
thus  be  divided  one  after  the  other  without  the 
necessity  of  removing  the  instrument  from  the 
urethra. 

It  is  advisable  in  cases  of  comparatively  tight 
and  very  dense  stricture,  where  a  great  dispropor- 
tion exists  between  the  normal  caliber  of  the  ure- 
thra and  the  caliber  of  the  undistended  stricture, 
not  to  attempt  a  complete  division  of  the  strictur- 
ing  bands  at  one  stroke,  as  the  great  amount  of 
traction  required  to  accomplish  a  full  distention  of 
the  stricture  would  threaten  a  circular  rupture  of 
the  urethra  on  a  line  just  beyond  the  proximal 
limit  of  the  stricture.  It  has  been  found  much 
safer  and  also  easier  to  cut  such  strictures  gradatim. 
What  is  meant  is  this :  that,  the  instrument  being 
introduced,  the  first  cut  is  to  be  made  at  a  moder- 
ate degree  of  dilatation.  The  knife  being  slij)ped 
back,  and  the  instrument  somewhat  closed,  it  is 
again  passed  behind  the  stricture,  when  a  second 
cut  is  made,  the  dial  indicating  this  time  five  or 
ten  millimetres  more  of  dilatation  than  was  accom- 
plished by  the  first  cut.  And  this  should  be  re- 
peated until  thus  gradually  full  division  is  accom- 
plished. 

For  very  tight  strictures  Maisonneuve's  instru- 
ment is  most  proper.     (Fig.  247.) 
Careful  disinfection  of  the  surgeon's  hands  and  instruments,  and  irri- 
gation of  the  urethra  with  a  watery  tepid  solution  of  permanganate  of  pot- 
ash (1  :  2,000),  should  precede  every  step  or  operation  that  may  lead  to 
wounding  of  the  urethral  mucous  membrane.     As  a  lubricant,  iodoform- 


TREATMENT  OF  GONORRHCEA.  345 

ized  vaseline  (1  :  30)  should  be  used.  The  operation  should  terminate  with 
a  renewed  irrigation  of  the  urethra. 

Whenever  strictures  are  cut  that  have  their  seat  near  the  bulbo-mem- 
branous  junction,  a  new,  large-sized,  English  elastic  catheter  should  be 
tied  into  the  bladder  for  twelve  hours,  and  the  patient  should  be  kept  in 
bed  for  a  day  or  two.  These  precautions  are  rarely  necessary  in  cutting 
strictures  located  in  the  pendulous  portion,  as  it  is  not  difficult  to  prevent 
haemorrhage  by  the  application  of  a  compressory  bandage  to  the  penis.  A 
gutter  of  light  pasteboard  is  applied  to  the  under  side  of  the  penis,  which 
is  first  enveloped  in  a  layer  of  cotton,  and  the  splint  is  firmly  secured  by  a 
few  turns  of  a  roller  bandage.  The  penis  and  scrotum  are  held  up  to  the 
belly  by  a  snugly-fitting  T-bandage.  This  preventive  appliance  can  be 
abandoned  on  the  second  day  after  the  operation. 

If  ammoniacal  urine  be  present,  its  condition  should  be  influenced  be- 
fore operation  by  the  internal  administration  of  boric  acid,  benzoate  of 
soda,  lactic  acid,  or  turpentine,  so  as  to  become  at  least  of  neutral,  or  what 
is  still  better  of  acid,  reaction. 

A  full-sized  steel  sound  is  to  be  introduced  twice  weekly,  the  first  appli- 
cation not  to  commence  before  the  fifth  day  after  the  operation.  Much  pain 
to  the  patient  will  be  avoided  by  first  introducing  a  copiously  anointed 
smaller-sized  sound,  which  will  carry  a  good  deal  of  the  lubricant  into  the 
urethra,  and  will  render  the  subsequent  use  of  a  full-sized  instrument  com- 
paratively painless  and  easy. 

With  the  precautions  above  described,  the  author  has  not  observed  a  case 
of  urethral  fever  following  either  internal  urethrotomy  or  the  use  of  dilat- 
ing instruments  in  the  urethra.  His  experience  extends  over  seventy-one 
cases,  in  which  strictures  were  cut  successfully  from  within.  No  febrile  or 
inflammatory  complications  were  ever  observed. 

(5)  Deep  Urethral  Strictures. — Strictures  of  the  deep  urethra  are  located 
in  the  membranous  portion.  Their  development  is  preceded  by  a  stage 
of  epithelial  and  submucous  hyperplasia,  identical  with  the  process  observed 
in  the  anterior  urethra.  This  hyperplastic  condition  is  amenable  to  suc- 
cessful treatment  by  dilatation  and  caustics,  but  unheeded,  will  develop 
into  permanent  stricture. 

Internal  urethrotomy  of  a  deep-seated  stricture  is  a  much  more  grave 
undertaking  than  the  cutting  of  a  stricture  of  the  anterior  urethra.  Both 
the  danger  of  haemorrhage  and  the  difficulty  of  controlling  it,  should  it 
occur,  render  the  operation  serious.  Haemorrhage  from  the  jaosterior  part 
of  the  urethra,  lying  behind  the  "cut-ofl"  muscle,  may  long  remain  un- 
recognized on  account  of  the  absence  of  free  bleeding  from  the  meatus,  as 
the  escaping  blood  will  flow  back  into  the  bladder,  and  can  be  expelled  only 
with  the  urine.  For  these  reasons  treatment  by  gradual  dilatation  should 
be  carried  on  whenever  possible,  and  urethrotomy  should  be  reserved  for 
cases  only  that  do  not  yield  to  dilatation  after  patient  trial,  or  will  not 
brook  delay.  When  an  operation  is  decided  on  as  necessary,  external  ure- 
throtomy deserves  the  preference  over  the  internal  operation,  especially  in 


346  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

cases  complicated  hy  am  maniacal  cysfifis.  Heemorrhage  will  be  easy  to 
control.  The  good  draiuage  resulting  from  the  external  incision  will  pre- 
vent urine  infiltration,  and  ready  access  to  the  bladder  will  facilitate  anti- 
septic irrigations  of  the  organ. 

External  Urethrotomy. — The  anaesthetized  patient  is  brought  in  the 
lithotomy  position,  his  hands  being  bandaged  to  the  feet,  which  are  then 
wrapped  in  clean  towels,  wrung  out  of  corrosive-sublimate  lotion.  The 
peringeum  and  anal  region  being  shaved  and  rubbed  off  with  the  same 
lotion,  the  operation  begins.  Irrigation  of  the  wound  by  Thiersch's  solu- 
tion is  carried  on  during  the  entire  operation,  "When  a  staff  or  even  a  fili- 
form bougie  can  be  carried  into  the  bladder  to  serve  as  a  guide,  the  opera- 
tion will  offer  no  difficulty  whatever.  As  soon  as  the  urethra  is  opened  and 
the  stricture  exposed,  its  division  can  be  accomplished  by  the  use  of  a  blunt- 
pointed  tenotomy  knife.  External  urethrotomy  without  a  guide  is  not  as 
easy,  but  its  difficulties  can  be  overcome  by  jiatience  and  circumspection. 

While  an  assistant  exerts  gentle  jjressure  over  the  distended  bladder,  the 
bottom  of  the  urethral  wound  being  well  exposed  by  small,  sharp  retractors 
or  fiUets  of  silk  drawn  through  the  lips  of  the  urethral  incision,  one  or  two 
drops  of  urine  will  be  seen  exuding  from  one  or  another  point  of  the  strict- 
ure. A  fine  probe  is  inserted  into  the  point  in  question,  and  will  often 
penetrate  the  stricture.  A  narrow,  grooved  director  is  insinuated  along  the 
probe,  and  serves  to  guide  a  sharp-pointed  tenotomy  knife  through  the  con- 
traction, which  then  can  be  divided  without  ditficulty. 

Should  this  expedient  fail,  on  account  of  inflammatory  swelling  of  the 
tight  part  of  the  urethra,  suprapubic  aspiration  of  the  bladder  may  serve  to 
tide  over  the  difficulty.  Relief  of  the  distention  of  the  bladder  is  often  fol- 
lowed by  decrease  of  the  swelling,  and  a  few  hours  after  the  operation  urine 
will  be  found  escaping  through  the  urethra,  when  the  true  channel  can  be 
searched  out  and  dilated. 

Case. — N.  S.,  laborer,  aged  42,  impermeable  stricture  of  the  membranous  portion 
of  the  urethra.  March,  11,  1883. — External  urethrotomy  without  guide.  The  stricture 
being  exposed,  most  diligent  search  failed  to  ascertain  the  direction  of  the  channel, 
which  was  obscured  by  the  intumescence  and  great  vascularity  of  the  parts.  The  dis- 
tended bladder  was  finally  emptied  by  snprabubic  aspiration,  and  the  patient  was 
brought  to  bed.  Six  hours  later  the  bladder  had  refilled,  and  urine  was  seen  to  trickle 
from  the  wound  whenever  the  patient  strained.  Renewed  search  was  rewarded  by 
the  finding  of  the  right  track,  which  was  divided  on  the  grooved  director  without 
much  trouble  or  pain  to  the  patient.     May  20th.— 'P&t\ent  was  discharged  cured. 

A  modification  of  another  expedient,  proposed  by  the  venerable  Petit, 
was  also  successfully  employed  by  the  writer. 

Case  I. — John  Smith,  negro  hostler,  aged  thirty-one,  suffered  from  impermeable 
stricture  of  the  deep  urethra  with  dangerous  distention  of  the  bladder.  The  usual  ex- 
pedients for  entering  the  bladder  having  failed,  external  urethrotomy  was  determined 
upon,  and  was  carried  out  December  2,  1876.  The  distal  part  of  the  stricture  being 
exposed,  no  entrance  could  be  effected.  As  there  was  no  aspirating  needle  on  hand, 
a  slender  trocar  was  inserted  into  the  middle  of  the  strictural  mass,  and  was  pushed 
forward  in  the  direction  of  the  urethra,  toward  the  center  of  the  prostate,  under  the 


TREATMENT  OF  GONORRHCEA.  347 

guidance  of  the  left  index-finger  placed  in  the  rectum.  The  point  of  the  instrument 
was  several  times  caught  in  the  mass  of  the  prostatic  gland,  but  finally  entered  the 
median  canal  and  the  bladder,  this  being  attested  by  the  escape  of  urine.  A  grooved 
director  was  pushed  in  along  the  cannula,  which  was  withdrawn,  and  the  stricture  was 
divided  with  a  tenotomy  knife.  A  sharp  attack  of  fever  and  cystitis  followed,  but  the 
patient  fully  recovered,  and  was  discharged  cured,  March  5,  1877. 

Case  II. — George  G.,  saloonkeeper,  aged  forty,  acute  retention  due  to  impassable 
stricture  of  the  membranous  portion — the  pendulous  portion  also  the  seat  of  a  num- 
ber of  strictures  ;  in  fact,  the  entire  pendulous  and  membranous  portions  forming  one 
stricture.  July  26,  1888. — External  urethrotomy  withotit  guide,  at  the  German  Hos- 
pital. The  urethra  could  be  felt  throughout  as  a  cord-like,  hard  mass.  This  was 
incised  in  the  region  of  the  urethral  bulb,  and  hence  a  filiform  bougie  could  be  intro- 
duced in  a  retrograde  direction  toward  the  end  of  the  penis.  Division  of  strictures  by 
Maisonneuve's,  then  by  Otis's  urethrotome.  The  proximal  part  of  the  urethra  could 
not  be  recognized;  hence  a  fine,  long  trocar  was  thrust  through  the  cicatrix  and  the 
middle  of  the  prostate  into  the  bladder,  then  this  track  was  dilated  with  the  knife, 
and  a  lai'ge  soft  catheter  was  left  in  situ  traversing  the  whole  urethra.  No  fever 
or  reaction  followed,  and  the  urine  became  acid.  August  25th. — Patient  was  dis- 
charged cured,  with  directions  to  use  a  sound. 

Strictures  located  in  the  anterior  urethra  can  be  simultaneously  divided 
by  Gerster's  urethrotome  or  the  tenotomy  knife  before  the  patient  recovers 
from  the  anaesthetic.  The  bladder  is  then  washed  out  with  Thiersch's  solu- 
tion, and  the  wound  is  dressed  with  a  pad  of  iodoformed  and  a  comjDress  of 
sublimated  gauze,  held  in  place  by  a  T-bandage.  In  the  presence  of  fetid 
urine,  the  use  of  a  drainage-tube  is  advisable.  Before  applying  the  dress- 
ings the  wound  should  be  rubbed  out  with  a  small  sponge  dipped  in  iodo- 
form jDOwder.  Anointing  of  the  joerinaeum  and  buttocks  with  vaseline  is 
necessary  to  prevent  eczema.  The  external  dressings  ought  to  be  changed 
whenever  soaked  ;  the  iodoform  pads,  however,  should  not  be  disturbed 
without  necessity  as  long  as  they  are  adherent.  Daily  sitz-baths  in  a  weak 
(1  :  10,000)  corrosive-sublimate  solution  will  tend  to  increase  the  comfort 
of  the  patient,  and  will  aid  the  healing  of  the  wound. 

The  daily  introduction  of  a  full-sized  steel  sound  need  not  be  commenced 
before  the  fifth  day,  and  should  be  continued  at  increasing  intervals  for  at 
least  a  year  after  the  operation. 

Altogether,  the  author  performed  external  urethrotomy  twenty-seven 
times.  Twenty-four  patients  recovered,  three  died.  The  fatal  cases  were 
as  follows  : 

Case  I. — Mr.  S.  O.,  tailor,  fifty-four  years  old,  sufi"ering  from  tight,  deep-seated 
stricture  of  the  urethra,  complicated  with  purulent  and  fetid  pyelo-nephritis.  The 
urine  remained  ammoniacal,  and  the  fistula  never  closed.  He  died,  August  5,  1886,  of 
urasmia,  five  months  after  the  operation,  done  March  25,  1886. 

Case  II. — Abraham  Goldfish,  aged  seventy-seven,  suffering  from  deep-seated  ure- 
thral stricture,  fetid  cystitis,  and  extensive  urine  infiltration  of  the  perineum,  due  to  a 
false  passage  made  by  a  physician.  External  urethrotomy  was  performed,  November 
1,  1886,  at  Mount  Sinai  Hospital,  with  much  relief  of  the  subjective  symptoms,  but 
the  patient  succumbed  to  septicsemia  and  septic  nephritis  on  November  18,  1886. 

Case  III. — Christian  Schlenker,  engineer,  aged  twenty-seven.  Tight  stricture  of 
46 


348  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

membranous  portion,  with  chronic  fetid  cystitis  and  pyelo-nephritis.  External  nre- 
throtomy,  June  3,  1887,  at  tlie  German  Hospital.  The  urgent  symptoms  were  abated, 
but  the  patient  continued  to  have  fever,  lapsed  into  hectic,  and  died  August  24,  1887. 
The  autopsy  revealed  far-gone  double  tuberculous  nephritis. 

One  case  deserves  special  mention  on  account  of  its  rarity  : 

Case. — S.  E.,  shopkeeper,  aged  sixty-three,  sustained,  in  1875,  a  compound  fracture 
of  the  left  horizontal  ramus  of  the  os  jjuhis,  from  which  he  recovered  after  a  long  term 
of  illness.  In  the  spring  of  1882  increasing  difficulty  of  micturition  became  noticeable, 
and  finally  led  to  retention  of  urine.  June  25,  18S2. — The  author  saw  the  case  in  con- 
sultation with  Dr.  I.  Schnetter.  A  metallic  sound  could  be  passed  easily  as  far  as  the 
membranous  portion,  but  was  there  arrested  by  a  grating,  hard  body,  thought  to  be  a 
sequestrum  or  a  stone.  External  urethrotomy  was  done  June  27th,  and  an  irregularly 
shaped  sequestrum,  one  inch  long  and  one  sixth  of  an  inch  thick,  was  withdrawn  with 
some  difficulty.     Patient  recovered  without  fistula,  and  was  cured  in  about  six  weeks. 

Three  times  external  urethrotomy  was  successfully  done  for  deep-seated 
stricture  and  the  relief  of  coexistent  prostatic  abscess.  Four  times  internal 
and  external  urethrotomy  were  done  simultaneously.  In  four  cases  per- 
manent lip-shaped  fistulae  remained  behind  and  required  closure  by  Szyma- 
novsky's  plastic,  which  succeeded  in  each  instance.  In  one  of  these  cases 
internal  urethrotomy  of  two  strictures  of  the  pendulous  portion  was  done 
simultaneously  with  Szymanovsky's  plastic  successfully. 

b.  Vegetations  of  the  Urethra. — Venereal  vegetations,  such  as  are 
frequently  observed  under  the  prepuce  of  men  suffering  from  gleet,  occa- 
sionally occur  in  the  urethra,  principally  in  the  fossa  navicularis  and  in 
the  sinus  bulbi.  They  maintain  a  rebellious  urethral  discharge  that  can  be 
stopped  only  by  their  removal.  Their  diagnosis  can  be  made  by  the  aid  of 
the  endoscope,  which  also  affords  the  best  means  of  access  for  their  treat- 
ment. The  use  of  the  curette,  or  a  small  wire  snare,  or  of  chromic  acid  in 
crystals,  will  readily  destroy  them,  and  will  terminate  the  urethral  discharge 
depending  on  their  presence. 

c.  Granular  Urethritis. — One  of  the  most  tedious  affections  of  the 
urethra  is  a  chronic  inflammation  of  the  mucous  membrane  following  an 
attack  of  acute  gonorrhoea,  characterized  by  an  irregularly  distributed  hyper- 
aemia  and  scanty  discharge.  The  velvety  mucous  membrane  bleeds  at  the 
slightest  touch,  and  the  condition  resists  every  form  of  local  treatment  for 
a  disproportionately  long  time.  It  seems  that  the  intractability  of  this 
affection  depends  in  a  great  measure  upon  constitutional  disorders  ;  at  least 
the  author  observed  it  most  frequently  in  ansemic  individuals  of  a  scrofulous 
habit.  Measures  directed  to  the  improvement  of  the  general  condition,  and 
supplemented  by  the  local  application  of  a  five-per-cent  sohition  of  nitrate 
of  silver  by  the  endoscope,  seem  to  have  been  more  efficient  than  anything 
else,  though  it  must  be  admitted  that  a  few  cases  resisted  ever}'  kind  of 
treatment,  and  had  to  be  given  up  as  entirely  unmanageable. 

d.  Chronic  Catarrh  of  the  Posterior  Part  of  the  Urethra, 
AND  Chronic  Cystitis.  —  Chronic  catarrh  of  the  membranous  and  prostatic 


TREATMENT  OF  GONORRHCEA.  349 

part  of  the  urethra  is  frequently  observed  following  an  acute  attack  of  gon- 
orrhoea, in  subjects  formerly  addicted  to  masturbation,  or  those  indulging 
in  general,  and  especially  in  sexual,  excesses.  In  these  cases  no  external 
urethral  discharge  is  visible,  but  frequent  micturition  is  present,  and  both 
portions  of  the  urine,  passed  into  two  tumblers,  show  turbidity,  the  first 
portion,  however,  being  more  turbid  than  the  last. 

Treatment  by  gradual  dilatation  with  full-sized  sounds  is  perfectly  use- 
less in  this  affection,  and  may  even  lead  to  epididymitis  in  some  cases. 
Metliodical  irrigation  of  the  neck  of  the  Uadder,  on  the  other  hand,  by  means 
of  a  soft  gum  catheter  and  hand  syringe,  as  described  in  a  preceding  para- 
graph, will  be  very  often  found  beneficial.  Of  all  substances,  a  1  :  2,000 
tepid  solution  of  permanganate  of  potash  has  been  found  most  generally 
applicable.  A  quart  china  bowl  is  filled  with  warm  water,  and  enough  of  a 
concentrated  solution  of  the  salt  is  added  to  tinge  the  water  a  light-claret 
color.  This  test,  by  observing  the  depth  of  the  tinction,  is  very  sensitive 
if  applied  to  weak  solutions,  and  commends  itself  by  its  simplicity.  Next 
to  permanganate  of  potash,  one-per-cent  solutions  of  sulplio-carbolate  of 
zinc  or  of  acetate  of  lead  deserve  mention.  But  nitrate  of  silver  is  the 
most  efjicient  of  all  known  remedies  in  obstinate  cases  of  chronic  deep-seated 
urethritis  or  prostatic  catarrh.  A  few  drops  of  a  five-per-cent  solution  are 
instilled,  twice  or  three  times  a  week,  by  Ultzmann's  or  Keyes's  deep  ure- 
thral syringe,  as  formerly  described. 

Acute  cystitis,  whether  gonorrlioeal  or  pyogenic,  is  not  amenahle  to  in- 
strumented treatment,  ivhich  should  only  commence  after  the  cessation  of  the 
invasive  stage.  The  object  of  medicinal  irrigation  is  the  disinfection  and 
removal  of  fermenting  urine  and  its  decomposed  contents,  such  as  ropy 
mucus,  blood,  and  j)us. 

If  stone  or  a  stricture  be  the  causative  agents,  they  must  be  removed  ;  if 
imperfect  evacuation  of  the  bladder,  on  account  of  paresis,  or  enlargement 
of  the  prostate,  is  at  the  bottom  of  the  trouble,  regulated  evacuation  of  the 
organ  by  catheterism  must  be  employed.  Aside  from  fulfilling  these  causal 
indications,  recovery  can  be  materially  hastened  by  methodical  irrigation. 

IriHgation  ivith  a  metallic  '^ clouhle  current^'  catheter,  as  recommended  hy 
various  authors,  is  unsatisfactory.  Introduction  of  the  rigid  catheter  is 
painful,  and  may  be  the  source  of  various  complications.  The  advantages 
of  the  double  current  are  illusory,  as  much  of  the  ropy  mucus  and  other 
sediment  found  in  the  cul-de-sac  of  the  bladder  is  not  brought  out  by  its 
use.  A  more  gentle  and  much  more  efiicient  way  of  thoroughly  emptying 
the  deleterious  contents  of  the  inflamed  bladder  is  as  follows  : 

The  patient  is  made  to  stand  before  the  seated  physician.  This  position 
is  more  favorable  than  any  other,  as  in  it  the  sedimental  matter  contained 
in  the  urine  is  made  to  gravitate  toward  the  neck  of  the  bladder,  where  it 
is  readily  stirred  up  and  evenly  distributed  in  the  urine  by  the  injections. 
Thus  it  will  pass  the  catheter  much  easier  than  when  it  forms  a  sticky  mass. 
A  soft  rubber  catheter  is  introduced  into  the  bladder,  and  a  hand-syringeful 
of  a  tepid,  weak  solution  of  cooking-salt  (one  teaspoonful  to  a  quart,  about 


350  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

6  :  1,000)  is  thrown  in  gently,  and  is  allowed  to  escape  at  once.  This  is 
repeated  until  the  returning  saline  solution  is  clear  and  limpid.  After  this, 
two  or  three  ounces  of  a  tepid  1  :  5,000  solution  of  permanganate  of  potash 
are  injected  and  retained  for  one  or  two  minutes,  and  the  process  is  repeated 
until  the  returning  fluid  ceases  to  be  discolored.  By  and  by,  as  the  bladder 
becomes  more  tolerant,  the  injection  should  be  made  more  forcible,  as  a 
thorough  stirring  up  and  dislodgment  of  the  ropy  sediment  by  the  Jet  of 
lotion  is  very  essential  to  its  complete  evacuation.  The  strength  of  the 
medicinal  lotion  should  also  be  gradually  increased  (to  1  :  1,000). 

In  cases  of  paresis,  or  when  a  tendency  to  vesical  haemorrhages  be  pres- 
ent, cold,  instead  of  tepid,  injections  will  be  appropriate. 

In  obstinate  catarrh  the  strength  of  the  permanganate-of-potash  lotion 
can  be  increased  to  3  :  1,000.  Alum  (from  1  :  100  to  5  :  100),  sulphate  of 
zinc  (from  1  :  100  to  2  :  100),  and  nitrate  of  silver  (from  ^  :  100  to  2  :  100), 
will  also  be  found  very  effective.  Deodorization  of  fetid  urine  is  readily 
effected  by  injections  of  a  3  :  100  solution  of  resorcine,  which  should  be 
followed  up  by  the  employment  of  one  or  another  of  the  medicinal  solutions 
above  mentioned  (Ultzmann). 

If  the  capacity  of  the  bladder  be  very  much  diminished  by  long-con- 
tinued spastic  contraction  accompanying  gonorrhoeal  or  calculous  cystitis, 
gentle  and  gradual  distention  of  the  organ  by  salt  water  or  medicinal  in- 
jections of  increasing  volume  will  be  followed  by  increasing  tolerance. 
Thus  micturition  will  gradually  become  less  frequent,  and  the  normal  con- 
dition of  things  may  be  re-established. 

Note. — Gradual  distention  of  the  shrunken  bladder  of  elderly  persons  is  dangerous,  as  it 
may  lead  to  rupture  of  diverticula. 


PAKT    V 


SYPHILIS 


ASEPTIC    AND    ANTISEPTIC    TEEATMENT 
OF    ITS    EXTEENAL    LESIONS. 


CHAPTER  X. 

ASEPTICS  AND  ANTISEPTICS  APPLIED    TO  EXTERNAL   SYPHILITIC 

LESIONS. 

1.  Aseptic  Treatment  of  Primary  Induration. — The  nature  of  the  specific 
virus  of  syphilis  is  not  known.  In  most  cases  its  local  and  general  mani- 
festations are  amenable  to  appropriate  systemic  and  topical  remedies. 

It  is  not  intended  here  to  dwell  upon  the  nature  and  treatment  of 
syphilis  as  a  general  disease  ;  only  inasmuch  as  some  of  its  more  common 
local  phenomena  require  surgical  treatment  will  their  consideration  be 
deemed  within  the  limits  of  this  chapter. 

The  anatomical  structure  of  the  primary  induration,  of  tuberous  syphi- 
lides,  and  of  gummy  swellings,  resembles  closely  that  of  recent  tuberculous 
deposits ;  and  their  course  of  development  and  termination  in  central 
coagulation  necrosis,  fatty  changes,  or  caseation,  also  bears  much  general 
resemblance  to  the  affections  caused  by  the  bacillus  of  tuberculosis.  But 
there  is  a  third  point  of  parallelism. 

As  long  as  softened  tuberculous  or  syphilitic  foci  remain  subcutaneous, 
and  are  not  exposed  to  the  influence  of  the  air  and  its  pus-generating  germs, 
their  course  is  bland  and  slow,  and  their  tendency  is  to  fatty  degeneration, 
encapsulation,  and  final  absorption.  But,  as  soon  as  such  a  softening  deposit 
comes  under  the  influence  of  the  pyogenic  elements  contained  in  the  at- 
mospheric air,  its  slow  and  bland  character  is  changed  to  a  most  destructive 
one.  Thus  syphilitic  nodes  of  the  internal  organs,  being  protected  from 
contact  with  the  outer  air,  rarely,  if  ever,  terminate  in  ulcerative  destruc- 
tion :  they  generally  tend  to  fatty  involution,  absorption,  and  cicatrization. 
Specific  deposits  of  the  outer  skin,  the  mucous  membranes — as,  for  example, 
of  the  nasal  and  oral  bones — on  the  other  hand,  are  all  noted  for  their  pro- 
nounced tendency  to  rajjid  ulceration  or  gangrenous  destruction. 

As  an  illustration  of  a  parallel  behavior  of  tuberculous  foci,  cold  ab- 
scesses and  articular  tuberculosis  may  be  mentioned.  Before  perforation, 
their  course  is  mild  and  slow  ;  but  after  the  establishment  of  one  or  more 
sinuses  they  become  the  source  of  profuse  secretion,  and  their  course  is 
characterized  by  rapid  local  destruction  with  general  emaciation. 

The  explanation  of  this  peculiar  difference  in  the  behavior  of  syphilitic 
indurations  or  tumors,  essentially  identical  in  morbid  character,  is  to  be 
found  in  the  fact  that  the  poor  nutrition  and  low  vitality  of  the  cellular 


354  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

elements  composing  a  primary  or  secondary  syjiliilitic  node,  exposed  to 
pyogenic  infection  by  contact  with  the  outer  air,  offer  very  favorable  con- 
ditions for  the  rapid  development  and  destructive  multiplication  of  germs, 
that  are  notoriously  deleterious  even  to  healthy  tissues.  Pus-generating 
cocci  deposited  on  the  excoriated  surface  of  a  syphilitic  focus,  as,  for  in- 
stance, a  primary  induration  of  the  prepuce,  or  a  gummy  swelling  of  the 
nasal  bones,  will,  by  their  multiplication,  lead  to  massive  invasion  and  rapid 
ulcerative  destruction  of  the  densely  infiltrated  and  poorly  nourished  node. 

Syphilitic  ulcers  of  every  hind  present  a  combination  of  sypliilitic  and  of 
pyogenic  infection. 

If  we  succeed  by  appropriate  systemic  treatment  in  preventing  the  ex- 
tension of  the  central  softening  of  a  syphilitic  node  to  the  surface,  ulcerat- 
ive changes  also  will  thus  be  prevented.  For  example,  the  timely  admin- 
istration of  large  doses  of  iodide  of  potash  may  prevent  necrosis  of  the  nasal 
bones,  which  are  the  seat  of  a  growing  gummy  swelling.  Their  dense  infil- 
tration pertains  to  syphilis  ;  their  necrosis,  however,  is  caused  by  the  invasion 
of  pyogenic  germs.  But  we  possess  another  means  for  preventing  ulcerative 
destruction  of  syphilitic  deposits  located  in  the  outer  skin.  They  are  more 
exposed  to  pyogenic  infection,  but  they  are  also  more  accessible  to  local 
remedies. 

The  aseptic  protection  of  the  surface  of  the  primary  induration  offers  cm 
easy  remedy  for  preventing  the  formation  of  the  primary  ulcer  or  chancre. 

True,  that  the  prevention  of  the  ulcerative  destruction  of  a  primary  in- 
duration of  the  prepuce  will  not  prevent  the  systemic  development  of 
syphilis  ;  but  it  will,  nevertheless,  constitute  a  valuable  service  rendered  to 
the  patient,  who  will  be  spared  all  the  suffering,  annoyance,  and  danger 
connected  with  the  development  of  the  primary  ulcer. 

If  a  patient,  exhibiting  a  recent  primary  induration  of  the  penis,  pre- 
sents himself  for  treatment  before  the  appearance  of  the  pustular  excoria- 
tion, or  before  the  epidermal  film  of  the  formed  pustule  is  broken,  and  if 
the  surgeon  thoroughly  cleanses  and  disinfects  the  affected  parts,  afterward 
carefully  enveloping  the  penis  in  an  aseptic  dry  dressing,  ulceration  of  the 
indurated  node — that  is,  the  development  of  a  primary  ulcer — can  be  effectu- 
ally prevented. 

The  node  will  lose  its  epidermidal  covering,  but  the  aseptic  dressing  will 
exclude  pyogenic  infection,  and  the  course  of  development  and  involution 
of  the  syphilitic  deposit  will  be  as  though  it  were  subcutaneous.  A  small 
quantity  of  lymph  will  exude  from  the  excoriated  surface,  will  be  imbibed 
by  the  aseptic  dressing,  and  will  exsiccate,  thus  forming  a  hermetic  seal 
and  protection  to  the  diseased  tissues. 

Fatty  disintegration  of  the  infiltrated  tissues  will  be  followed  by  the 
formation  of  new  epidermis,  and  when,  after  three  or  four  weeks,  the  dress- 
ings come  off,  a  cicatrized  though  still  somewhat  indurated  portion  of  skin 
will  be  exposed  to  view. 

Specific  rash,  and  other  manifestations  of  systemic  infection,  will  appear 
in  due  course  of  time  :  but  the  incalculable  extension  of  the  ulceration  to 


ASEPTICS   AND  ANTISEPTICS  IN  SYPHILITIC  LESIONS.     355 

adjoining  non-infiltrated  parts  of  the  skin,  and  the  formation  of  suppurat- 
ive buboes  and  other  complications,  will  be  obviated.  The  following  case 
may  serve  as  an  illustration  : 

Case. — H.  B.,  aged  twenty-five,  presented  himself  January  2,  1887,  with  a  hard, 
elevated  node,  the  size  of  a  nickel,  occupying  the  dorsum  penis,  and  another  smaller 
induration  near  the  frenulum.  Suspicious  cohabitation  had  been  indulged  in  for  some 
time  until  within  a  few  days  of  the  visit.  Bilateral  indolent  iuguinal  lymphadenitis 
was  noted,  and  the  presence  of  specific  infection  was  assumed.  The  patient  was  kept 
under  daily  observation,  and  was  directed  not  to  meddle  with  any  blister  that  might 
appear  on  the  indurated  spots.  January  8th. — A  yellowish  discoloration  was  observed 
occupying  the  apex  of  the  larger  node,  and  was  looked  upon  as  an  indication  that  a 
pustule  was  forming.  The  entire  penis  was  carefully  cleansed  with  green  soap  and 
warm  water,  and  was  disinfected  with  a  1 : 1,000  solution  of  corrosive  sublimate,  good 
care  being  taken  not  to  break  the  transparent  layer  of  epidermis  covering  the  dis- 
colored spot.  A  thick  layer  of  iodoform  powder  was  sprinkled  over  both  indurated 
nodes,  and  a  small  patch  of  iodoformized  gauze  was  placed  over  them — this  being  held 
down  by  a  narrow,  oblong  compress  of  corrosive-sublimate  gauze,  snugly  bandaged  on 
with  a  muslin  roller.  The  meatus  was  left  exposed  for  micturition,  and  the  patient 
was  directed  not  to  interfere  with  the  dressings  and  to  report  daily.  The  first  dress- 
ing remained  undisturbed  until  January  17lh,  when  its  external  part,  getting  disar- 
ranged, was  removed.  The  strip  of  iodoform  gauze  was  found  firmly  attached  to  the 
underlying  indurated  nodes,  and  had  the  appearance  of  a  hard,  flat  cake,  that  had  been 
evidently  soaked  through  by  lymph  or  serum  some  time  since  its  application.  Evap- 
oration of  its  aqueous  contents  had  converted  it  to  the  shape  just  described.  It  was 
left  in  situ,  and  a  fresh  outer  dressing  was  applied. 

At  the  same  date  (January  17th)  the  girl  with  whom  the  patient  had  held  com- 
merce, presented  herself  for  examination  at  the  author's  request,  and  was  found  to  be 
covered  with  a  small,  papulous,  specific  rash.  The  appearance  of  her  throat,  the  uni- 
versal adenitis,  and  two  freshly-cicatrized  spots  on  the  labia  minora,  left  no  doubt  of 
her  being  subject  to  florid  syphilis.  She  remained  under  prolonged  specific  treat- 
ment, and  in  July,  1887,  still  exhibited  pharyngeal  ulcerations. 

January  25th. — The  dressings  applied  to  the  patient's  penis  became  again  disar- 
ranged, and  had  to  be  renewed.  The  immediate  covering  of  the  nodes,  consisting  of 
iodoform  gauze,  was  still  firmly  adherent,  and  was  left  unchanged. 

February  12th. — A  general  maculous  rash  appeared  on  the  patient's  body,  and  sys- 
temic treatment  by  mercurial  inunctions  was  commenced. 

February  20th. — The  entire  dressings  came  off — the  strip  of  iodoform  gauze  in  the 
shape  of  a  perfectly  dry  scab,  to  the  inner  side  of  which  was  found  attached  a  patch 
of  shiny  scales,  consisting  of  effete  epidermis.  The  noc^es,  which  were  formerly  promi- 
nent, had  receded  to  the  level  of  the  surrounding  skin,  and  the  induration,  which  still 
could  be  felt,  was  marked  by  a  coat  of  fresh-looking  young  epidermis.  The  patient 
received  fifty  inunctions  of  blue  ointment,  which  freed  him  from  all  cutaneous  symp- 
toms of  the  disease.  In  May,  pharyngeal  ulcerations  appearing,  the  inunctions  were 
resumed.    Size  and  hardness  of  the  initial  sclerosis  were  visibly  diminished  by  this  time. 

It  seems  in  the  foregoing  case  that  the  ulcerative  destruction  of  the  pri- 
mary induration  was  forestalled  by  disinfection  and  subsequent  aseptic 
management.  Without  them  the  imminent  formation  of  an  initial  sore  would 
have  inevitably  occurred.  The  treatment  of  the  fully-developed  chancre 
would  certainly  have  been  a  much  more  disagreeable,  painful,  and  filthy  ex- 
47 


356  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

perience  than  the  simple  manipulation  of  once  cleansing  and  protecting  the 
initial  induration.  The  site  of  the  morbid  process  thus  protected  against  "ex- 
ternal irritation" — that  is,  pyogenic  infection — ran,  as  it  were,  a  subcuta- 
neous and  bland  course  of  slow  involution,  the  aggregate  of  discharge  during 
forty-three  days  not  exceeding  the  small  quantity  required  to  permeate  a 
strip  of  four  layers  of  iodoformized  gauze,  covering  an  area  of  about  two 
thirds  of  a  square  inch. 

2.  Antiseptic  Treatment  of  the  Primary  Syphilitic  Ulcer. — The  results 
obtained  by  the  various  time-honored  and  well-established  forms  of  local 
treatment  of  the  primary  syphilitic  ulcer  all  bear  out  the  assumption  that 
the  specific  alteration  of  the  affected  tissues  only  serves  as  a  predisposing 
condition  to  the  subsequent  ulcerative  destruction  of  the  initial  sclerosis. 
The  ulceration  is  directly  produced  by  the  ingrafting  of  purulent  infection 
on  a  soil,  devitalized  by  the  dense  cellular  infiltration,  characteristic  of 
initial  sclerosis.  The  rapid  destruction  observed  in  chancre  is  always  sig- 
nalized by  the  detachment  of  the  epidermis  raised  in  the  shape  of  a  pustule, 
under  which  we  find  a  yellowish,  brittle  necrobiotic  nucleus,  which  is  the 
first  to  succumb  to  the  onslaught  of  the  pyogenic  organisms,  deposited  on 
it  by  the  manipulations  of  the  patient  or  otherwise. 

The  various  forms  of  local  treatment  successfully  employed  for  the  cure 
of  chancre  are  all  antiseptic  in  character. 

Their  aim  is  either  the  prompt  removal  of  the  infectious  discharge  by 
prolonged  baths  and  frequent  moist  dressings,  or  disinfection  by  weak  or 
concentrated  caustics,  or  a  combination  of  measures  directed  toward  a  rapid 
mechanical  removal  of  the  deleterious  secretions,  with  chemical  disinfection. 
As  the  most  powerful  and  most  effective  arrester  of  the  destructive  course 
of  phagedenic  chancre,  the  actual  cautery  is  to  be  mentioned — the  sover- 
eign destroyer  of  all  microbial  parasites. 

a.  Chemical  Steeilizatioist  and  Sueface  Drainage  by  Medicated 
Moist  Dressings. — The  energy  to  be  applied  to  the  local  treatment  of  an 
ulcerating  initial  sclerosis  should  be  proportionate  to  the  virulence  and  de- 
structiveness  of  the  morbid  process.  In  most  cases  the  resistance  of  the 
vital  forces  combating  the  morbid  process  will  be  sufficient  to  check  the 
damage.  This  is  attested  by  the  numerous  cases  of  neglected  chancre  that 
end  ultimately  in  spontaneous  cure.  Hence,  in  most  instances,  a  mild 
treatment  by  local  antiseptic  baths,  combined  with  moist  antisej^tic  dress- 
ings, will  answer  the  purpose. 

Frequent  removal  of  the  soiled  dressings  forms  the  most  essential  part 
of  this  plan  of  therapy.  The  patient  is  directed  to  provide  himself  with  a 
wide-mouthed,  one-ounce  vial,  which  is  filled  with  suitably  proportioned 
small,  square  pieces  of  lint  or  gauze,  over  which  is  jioured  a  moderate  quan- 
tity of  a  one-per-cent  solution  of  carbolic  acid,  or  a  1  :  5,000  solution  of 
corrosive  sublimate.  The  cork-stoppered  vial  can  be  easily  carried  by  the 
patient,  who  is  enjoined  to  dress  the  sore  or  sores  at  least  once  every  hour, 
and  oftener  if  the  discharge  be  very  profuse.  In  the  morning  and  evening 
a  prolonged  local  bath  in  the  same  solution  is  advisable.     In  many  cases 


ASEPTICS  AND  ANTISEPTICS  IN  SYPHILITIC  LESIONS.      357 

this  plan  will  be  sufficient  to  check  the  extension  of  the  ulcer,  and  to  bring 
about  cleansing  of  its  bottom. 

Another  mild  form  of  antiseptic  treatment  consists  of  the  application  of 
iodoform  powder  to  the  ulcerating  surface.  The  objectionable  odor  of  the 
drug  can  be  excellently  masked  by  the  admixture  of  equal  parts  of  freshly 
roasted  and  ground  coffee.  As  soon  as  the  appearance  of  a  cicatricial  border 
is  apparent,  these  modes  of  treatment  should  be  abandoned  in  faror  of  the 
application  of  strips  of  mecurial  plaster,  which  should  be  renewed  in  pro- 
portion to  the  amount  of  discharge.  Cicatrization  will  be  very  much  has- 
tened by  this  change. 

h.  Chemical  Sterilization  by  Strong  Caustics. — Cases  of  greater 
virulence  which  do  not  yield  within  a  fortnight  or  so  to  the  mild  plan  of 
treatment  by  scrupulous  cleansing  and  disinfection,  or  in  which  rapid  ex- 
tension of  the  ulcer  does  not  justify  temporizing,  require  the  application  of 
escharotics.  The  author  has  found  a  fifty -per -cent  solution  of  chloride  of 
zinc  the  most  convenient  and  most  effective  of  all  chemicals  recommended 
for  the  cauterization  of  chancre.  Its  application  is  to  be  done  as  follows  : 
The  ulcer  and  its  vicinity  are  subjected  to  a  careful  cleansing  by  a  mop  of 
cotton  dipped  in  a  1  :  1,000  solution  of  corrosive  sublimate.  Crusts  and 
scabs  overlapping  the  edge  of  the  sore  must  be  gently  removed.  A  small 
piece  of  clean  blotting-paper  is  applied  to  the  ulcer  and  its  vicinity  with 
gentle  pressure  to  remove  all  moisture.  A  moderate  quantity  of  the  caustic 
solution  is  applied  to  the  sore  with  a  glass  rod  or  match-stick,  care  being 
taken  not  to  corrode  unnecessarily  the  surrounding  healthy  skin.  Previous 
thorough  drying  of  the  integument  with  blotting-paper  will  best  prevent 
overflowing  of  the  caustic.  All  the  nooks  and  indentations  of  the  margin 
of  the  ulcer  must  be  carefully  covered  by  the  solution.  As  soon  as  the  base 
of  the  sore  assumes  the  color  of  parchment,  which  will  occur  in  from  three 
to  five  minutes,  cauterization  is  completed,  whereu^ion  the  surplus  of  caustic 
should  be  removed  by  the  application  of  another  piece  of  blotting-paper. 
The  eschar  is  dusted  with  a  little  iodoform  and  coffee-powder,  and  is  pro- 
tected from  injury  by  a  strip  of  moist  lint  or  gauze. 

If  the  cauterization  was  sufficient,  further  extension  of  the  ulcerative 
process  will  be  arrested  thereby.  In  from  two  to  six  days,  according  to  the 
depth  of  the  eschar,  a  narrow  line  of  demarkation  will  appear,  and,  the 
eschar  being  detached,  a  healthy  granulating  surface  will  become  visible. 
This  should  be  dressed  with  strips  of  mercurial  plaster  until  cicatrization  is 
completed. 

Insufficient  chemical  cauterization  will  not  check  the  ulcerative  decay 
of  the  tissues.  In  proportion  to  the  incompleteness  of  the  application,  par- 
tial or  total  extension  of  the  ulcer  will  be  observed.  In  some  cases  only  a 
tongue  of  renewed  ulceration  will  be  seen  extending  outward  from  the  mar- 
gin of  the  eschar.  In  others,  the  ulceration  will  spread  all  around  the 
cauterized  patch,  thus  demonstrating  the  entire  inadequacy  of  the  applica- 
tion. The  surgeon's  error  should  be  in  favor  of  too  much  rather  than  too 
little  of  the  caustic. 


358 


RULES   OF  ASEPTIC  AND   ANTISEPTIC  SURGERY. 


When  the  process  is  found  to  be  extending  more  or  less  in  spite  of  a  pre- 
vious cauterization,  the  deficiency  should  be  corrected  without  delay  by  a 
renewed  application. 

c.  Sterilization  by  the  Actual  Cautery. — Phagedenic  forms  of 
chancre,  occui-ring  on  the  penis,  lips,  or  fingers,  and  characterized  by  dusky 
swelling  and  a  rapidly-spreading,  more  or  less  gangrenous  decay  of  the  tissues, 
can  be  rarely  arrested  by  anything  short  of  the  energetic  application  of  the 
actual  cautery.  In  some  cases  renewed  searing  will  be  required  to  check  the 
trouble  brought  under  control  in  one  portion  of  the  ulcer,  but  extending 
further  in  another  direction  from  a  limited  part  of  the  lesion.  It  is  espe- 
cially important  to  search  out  all  recesses  overlapped  by  the  undermined 
margin  of  integument,  as  they  are  the  chief  nidus  of  active  infection.  The 
thermo-cautery,  or  red-hot  iron,  should  be  well  inserted  in  all  of  these  re- 
cesses and  sinuses,  otherwise  the  result  will  be  incomplete  or  entirely  un- 
satisfactory. The  wound  should  be  packed  with  very  narrow  strips  of  iodo- 
form gauze  while  the  patient  is  still  under  the  influence  of  the  indispensable 
anaesthetic,  and  care  should  be  taken  to  line  all  nooks  and  crevices  of  the 
irregular  wound  with  the  gauze.  The  object  of  this  is  to  prevent  retention, 
and  to  secure  prompt  disinfection  of  the  discharges  which  needs  must  be 
absorbed  by  the  dressings.  The  penis  is  enveloped  in  an  ample  compress, 
moistened  with  warm  carbolic  lotion  (one  per  cent),  over  which  is  placed  a 
piece  of  rubber  tissue  to  prevent  evaporation.  On  the  penis,  daily  change 
of  dressings  is  to  be  done  after  a  hip-bath,  which  will  very  much  facilitate 
their  painless  removal.  The  febrile  disturbance  regularly  noted  with  these 
most  virulent  forms  of  specific  ulcer,  and  the 
general  debility  and  anaemia,  which  is  its 
main  predisposing  cause,  require  appropriate 
roborant  and  anti-febrile  general  treatment. 
As  soon  as  cicatrization  shall  have  com- 
menced, the  affection  is  to  be  treated  like 
a  simple  ulcer. 

The  foregoing  view  of  the  relation  of  sup- 
puration to  syphilitic  lesions  is  based  exclu- 
sively upon  clinical  data,  and  needs  corrobo- 
ration at  the  hands  of  pathologists  more  ex 
pert  in  systematic  and  exact  research  than 
the  author.     One  object  of  these  re- 
marks was   to   arrange   the   clinical 
facts  pertaining  to  syphilitic  ulcera- 
tions under  a  general  principle,  from 
which  the  therapeutic  measures  usu- 
ally employed  for  their  cure  could  be 
easily  and  logically  deduced. 


Specific  ulcer  of  index  fiuger. 


INDEX. 


Abbe's  catgut  rings  for  enterorrhaphy,  162. 
Abdominal  drainage,  120,  145. 

operations,  119. 

suture,  146. 

toilet,  145. 

tumors,  puncture  of,  144. 
Abscess,  anal,  285. 

of  bone,  219. 

cervical,  234. 

cold,  294. 

formation  of,  193. 

glandular,  203,  234,  259. 

of  liver,  276. 

lumbar,  276. 

mammary,  237. 

mastoid,  235. 

maturing  of,  194. 

metastatic,  195. 

pelvic,  260. 

perinephritic,  276. 

perityphlitic,  260. 

prevesical,  269. 

self-limitation  of,  194. 

temporal,  235. 

tonsillar,  229. 
Accidental  wounds,  29. 

definitive  care  of,  31. 

infection  of,  by  careless  probing,  30. 

temporary  care  of,  27. 
Accidents  in  and  after  tracheotomy,  102-104. 
Acetic  acid,  11. 

Active  movements  after  joint  exsection,  307. 
Actual  cautery  for  syphilitic  ulcers,  358. 
Adhesions,   treatment   of,   in    abdominal   tu- 
mors, 143. 
^ther  pneumonia,  152,  156,  157,  165. 

nephritis,  121. 
Amputation,  61. 

for  diabetic  gangrene,  63. 
Amputation  of  breast,  female,  1  ]  3. 
48 


Amputation  of  breast,  in  males,  117. 

statistics  of,  118. 

technique  of,  115. 
Amputation  of  limbs,  clean  cases,  64. 

hypersemia  and  oozing  after,  73. 

intensely  septic  cases,  67. 

mildly  septic  cases,  66. 

management  of  stump  after,  74. 

osteomyelitis  of  stump  in,  65. 

statistics  of,  61,  62. 
Amputations,  dressings  after,  75. 
Anaesthetics  in  herniotomy,  dangerous  depress- 
ing effect  of,  129. 
Anal  abscess,  285. 
Anal  fistula,  286. 

excision  of,  286. 

suture  of,  257. 

tuberculous,  299. 
Anatomy  of  connective-tissue  planes  of  neck, 

222. 
Anchylosis,  bony,  87. 
Aneurism,  axillary,  52. 

carotid,  49. 

cyrsoid,  52. 

femoral,  50,  51. 

innominate,  50. 

palmar,  50. 

popliteal,  50,  51. 
Ankle-joint,  exsection  of,  325, 
Antisepsis,  27,  183. 

Antiseptics  applied  to  primary  syphilitic  ul- 
cers, 356. 
Apncea  after  tracheotomy,  104. 
Apparatus  for  the  after-treatment  of  the  ex- 

sected  elbow-joint,  312,  313. 
Appendicitis,  261,  262. 

acute  perforative,  264. 

acute,  simple,  263. 

acute,  with  tumor,  265. 

chronic,  272. 


360 


INDEX. 


Appendicular  stenosis,  2(32. 
Aprons,  20. 

Arm,  suppuration  of,  252. 
Arteries,  ligature  of,  48. 
Arterio-phlebectasia  of  foot,  51. 
Artery,  deligation  of  axillary,  52. 

carotid,  common,  49,  186. 

carotid,  external,  52. 

femoral,  50,  51. 

iliac,  external,  50,  51. 

lingual,  97,  98,  99. 

operative  injury  of,  49. 

palmar,  50. 

ulnar,  50. 
Artery  forceps,  69. 
Arthrotomy,  78. 

for  dislocation,  82,  83. 

for  elbow  fracture,  83. 

for  habitual  dislocation,  8. 

for  joint-hydrops,  78. 

for  old  irreducible  dislocation  of  shoulder- 
joint,  83. 
Artificial  anaemia,  69. 

anus,  126. 
Asepsis,  3. 

in  peritoneal  operations,  1 19. 
Aseptic  cap,  92. 

accidental  wounds,  34. 

fever,  2r». 

operating,  manner  of,  17. 

wounds,  5. 
Aseptics  of  amputation,  64. 

no  excuse  for  bad  operating,  37. 

of  the  orifices,  96. 

of  rectum,  167. 
Aiitoinfection,  operative,  52. 
Axilla,  evacuation  of,  113. 
Axillary  glands,  252. 

vein,  59,  115. 

Bacteria  of  putrescence,  185. 

Bismuth,  11. 

Bladder,  aseptics  of  the,  173. 

treatment  of,  before  ovariotomy,  145. 
Elooddot,  healing  under  the,  6. 
Boiled  water  for  irrigation,  10. 
Bone  abscess,  219. 

tuberculosis,  303. 
Boro-salicylic  lotion,  li^. 
Bose's  method  of  tracheotomy,  102, 
Bottle-shaped  wounds,  41. 
Bow-leg,  86. 

Bozeman's  position,  168. 
Breast,  amputation,  113. 


Breast,  benign  tumors  of,  115. 
Bursa,  olecranic,  252. 

of  quadriceps,  257. 

prepatellary,  256. 
Button  sutures,  46. 

Cachexia  strumipriva,  112. 
Calculous  kidney,  279. 
Callus,  deformed,  88. 

Cancer  of  detached  lobe  of  mammary  gland, 
23. 

of  tongue,  97. 
Cancerous  Ivmph  glands,  54. 
Carbolic  acid,  10. 
Caries,  303. 
Carpal  exsection,  315. 
Caseation,  294. 
Caseous  infiltration,  294. 
Castration,  165. 
Cataplasms,  200. 
Catgut,  8. 

impure,  8. 

slipping  of,  5,  57. 
Catheterism,  159. 
Catheters,  cleansing  of,  1 74. 
Cervical  abscess,  173,  2-34. 
Change  of  dressings,  20. 
Chisels,  212. 
Cleanliness,  surgical,  7. 
Geansing  process  of  feet,  64. 
Club-foot,  88. 
Cold  abscess,  294,  303. 
Colotomy,  inguinal,  156. 

lumbar,  156. 
Compound  fracture,  16,  24,  31.  33,  34. 

of  cranium,  33. 
Compressor  urethrse,  333. 
Contaminated  accidental  wounds,  31. 
Continuous  suture,  46. 
Corrosive-sublimate  lotion,  10. 
Coryza,  scrofulous,  299. 
Cotton  dressings,  15. 
Creoline,  10. 
Crinoline  bandages,  15. 
"  Cut-off "  muscle,  333. 
C\Tiancbe,  parotid,  233. 

sublingual,  232. 
Cyst  of  broad  ligament,  149. 
Cystitis,  349. 
Cystotomy,  perineal,  177. 

suprapubic,  177. 
Czemy's  suture  for  hernia,  136. 

Definitive  care  of  accidental  wounds,  31. 


INDEX. 


361 


Deformities,  86. 
Diphtheria  of  fauces,  225. 

of  intestine,  129. 
Dislocation,  habitual,  82. 

irreducible,  82. 
Dissection,  technique  of,  36. 
Dissemination,  operative,  of  cancer,  53. 

of  tuberculosis,  318. 
Drainage,  47. 

abdominal,  120,  145. 

of  peritonaeum,  121. 
Drainage-tubes,  9. 

removal  of,  22, 

replacement  of,  48. 

T-shaped,  for  cystotomy,  178. 
Dressings,  11. 

change  of,  20. 

first  change  of,  in  infected  wounds,  27. 

for  hand  and  forearm,  83. 

patterns  for,  14. 
Dry  dressings,  12. 

spores,  192. 
Dust,  5. 

Dustless  operating-room,  7. 
Dyspnoea,  expiratory,  105. 

Elastic  ligatures,  9,  151. 

in  anal  fistula,  288. 
Elbow  apparatus,  312,  313. 

fracture,  83. 

joint,  exsection  of,  310. 
Embolism,  septic,  195. 
Emergencies,  23. 
Emphysematous  gangrene,  205, 
Empyema,  old,  242. 

recent,  241. 
Endoscope,  urethral,  340. 
Enterectomy,  158. 

Enterorrhaphy,     Lembert  -  Czerny's     method, 
159. 

Senn's  method,  162. 
Epididymitis,  tuberculous,  165,  299. 
Erysipelas,  184,  289. 

phlegmonous,  290. 
Esmarch's  bandage,  69. 
Estlander's  operation,  242. 
Excision  of  anal  fistula,  286. 
Exsection  of  ankle-joint,  325. 

of  elbow-joint,  310. 

of  hip-joint,  315. 

of  joints  for  tuberculosis,  305. 

of  knee-joint,  319. 

of  shoulder-joint,  308. 

of  wrist,  314. 


External  urethi'otomy,  345, 
Extirpation  of  axillary  glands,  115,  253. 

of  cervical  glands,  52,  60. 

of  inguinal  glands,  57,  58,  260. 

of  tumors,  52. 

Face,  carbuncle  of,  224. 
Fauces,  diphtheria  of,  225. 

Rose's  position  for  operations  in  the,  227. 
Faucial  suppuration,  225. 
Feet,  cleansing  process  of,  64. 
Femur,  necrotomy  of,  211. 
Fever,  aseptic,  20. 

septic,  193. 
Fibrinous  arthritis,  78. 
Finger-joints,  exsection  of,  251. 

suppuration,  250. 
Finger-nails,  cleansing  of,  7. 
Fistula  in  ano,  286. 

excision  of,  286. 

thoracic,  242. 

tubercular,  299. 
Floating  bodies,  79. 
Follicular  tonsillitis,  226. 
Foreign  bodies  in  larynx  and  trachea,  106, 

107. 
Fresh  cadavers,  infectiousness  of,  191. 
Funnel-shaped  wounds,  41. 

Gangrene,  diabetic,  amputation  for,  63. 

of  gut  in  herniotomy,  127. 
Gastrostomy,  154. 
Gauze,  14. 

corrosive-sublimate,  15. 

iodoformized,  15. 
Gerster's  urethrotome,  343, 
Giant  cell,  in  tuberculosis,  294, 
Glandular  tuberculosis,  299. 
Gleet,  339. 
Goitre,  111. 

tracheotomy  for,  113. 
Gonococcus,  331.  • 

Gonorrhoea,  331. 

acute,  333. 

anterior,  333. 

chronic,  339. 

deep-seated,  336. 

posterior,  336. 
Granular  urethritis,  348. 
Granulations,  infection  of,  198. 
Green  soap,  7. 
Gross  dirt,  192. 
Gunshot  fractures,  36. 
Gunshot  wounds,  35. 


362 


INDEX. 


Habituation  to  septic  influences,  197. 
Haemorrhage,  in  amputation  of  limb,  69. 

from  nutrient  artery  of  bone,  73. 

secondary,  8,  49,  72. 
Haemorrhoids,  167. 

Whitehead's  operation  for,  170. 
Hjemostatic  needle,  42. 

Hahn's  incision  for  exsection  of  knee-joint,  320, 
Hair,  aseptic  management  of,  92. 
Hand,  phlegmon  of,  244. 
Hernia,  congenital,  133. 

radical  operation  for,  133. 

radical  operation  of,  Czerny's,  136. 

radical  operation  of,  Macewen's,  137. 

strangulated,  123. 
Hernial  sac,  treatment  of,  1 24. 
Herniotomy,  121. 

castration  in,  135. 

dressings  after,  131. 

establishment  of  artificial  anus  in,  126. 

open  section  in,  12.5. 

radical,  for  congenital  hernia,  136. 

undescended  testicle  in,  13.5. 
Hilton-Roser's  method  of  incising  abscesses, 

204,  208. 
Hip-joint  exsection,  315. 
Hip-rest,  Yolkmann's,  131 
Hot  applications,  201. 
Hydrocele,  163. 

tapping  of,  164. 
Hygroma,  proliferating,  301 
Hysterectomy,  151. 

Immersion,  continuous,  249. 

Incision  of  knee-joint  for  suppuration,  256. 

Incontinentia  alvl,  288. 

Infected    wound,   first    change    of    dressings 

of,  27. 
Infection  by  impure  catgut,  8, 

of  accidental  wounds  by  careless  probing,  30. 

portals  of,  185. 
'  Infectiousness  of  tonsillitis,  226. 
Inflammation,  192. 
Ingrown  toe-nail,  253. 
Inguinal  glands,  suppuration  of,  239. 
Injections,  urethral,  333. 
Injury,  operative,  to  large  arteries,  49. 
Instrument-pouch,  26. 
Internal  urethrotomy,  342. 
Interrupted  suture,  44. 
Intubation,  101. 
Iodoform,  11. 

dusting  box,  15, 

mania,  99. 


Irrigation,  7. 

continuous,  249. 

of  joints,  76. 

of  the  neck  of  the  bladder,  336. 

of  the  urethra,  335. 
Irritation,  caloric,  190. 

by  drainage-tubes,  47. 

chemical,  190. 

mechanical,  189. 

Joint-exsection,  305. 

Joints,  after-treatment  of  excised,  307. 

hydrops  of,  78. 

tuberculosis  of,  305. 

Kidney,  surgical,  279. 
Klotz's  endoscope,  340. 

Knee-joint,  anchylosis  of,  in  vicious  position, 
87,  325. 

exsection,  technique  of,  319. 

floating  bodies  of,  80. 

hydrops  of,  78. 

suppuration  of,  256. 

tuberculosis  of,  319. 

vegetations  of,  79. 
Knock-knee,  86. 

Langenbeck's  rule  for  excision  of  tumors,  55. 
Lange's  position  for  nephrotomy,  277. 
Laparotomy,  exploratory,  139. 

treatment  of  navel  in,  140. 

warm  sponges  and  towels  in,  145. 
Laryngeal  operations,  100. 
Laryngofissure,  107. 
Larynx,  entrance  of  blood  into,  96. 

extirpation  of,  108. 

granuloma  of,  106. 
Laudable  pus,  198. 
Lawson  Tail's  aseptics,  120. 
Lead-plate  suture.  Lister's,  46. 
Leg,  ulcer  of,  255. 
Leptothrix,  228. 
Ligatures,  8. 

Litholapaxy,  Bigelow's,  175. 
Little  finger,  suppuration  of,  243, 
Liver  abscess,  276. 
Lumbar  abscess,  276. 

dressings,  278. 
Lupus,  298. 

Lymphadenitis,  caseous,  299. 
Lymphangitis,  199. 
Lymph  glands,  cancerous,  54. 

suppurating,  52,  203,  234,  253,  259. 

tuberculous,  299. 


INDEX. 


363 


Maas's  operation  for  defects  of  integument,  94. 

Malignant  tumors,  removal  of  capsule  of,  54. 

Mamma,  amputation  of,  113. 

Mammary  abscess,  237. 

Mastitis,  interstitial,  239. 

Mastoid  abscess,  235. 

Measles  and  tuberculosis,  295. 

Meatotomy,  339. 

Mechanical  irritation,  189. 

Mikulicz's  operation,  326. 

Moist  dressings,  13, 

Moss,  11. 

Mouth,  aseptics  of,  96,  97. 

Mucous  membranes,  tuberculosis  of,  299. 

Multiple  puncturing,  Volkmann's,  200. 

Myxoedema,  112. 

Xails,  arrangement  of,  87. 

extraction  of,  after  exsection  of  knee-joint, 
325. 

for  knee-joint  exsection,  321 
Neck,  caseous  lymphadenitis  of,  300. 

connective-tissue  planes  of,  222. 
Neck  of  the  bladder,  cauterization  of,  338. 

irrigation  of,  336. 
Necrosis  of  bone,  207. 

of  bone  by  evaporation,  13 

of  gut,  126. 
Necrotomy,  208. 
Needle  haemostatic,  42. 
Needle-holder^  41 
Nephrectomy,  abdominal,  153. 

lumbar,  281. 
Neuber's  implantation,  214. 

(Esophagus,  retrograde  catheterism  of,  154. 

cancer  of,  155. 
Olecranic  bursa,  252. 

Open  exsiccative  treatment  after  plastic  op- 
erations, 92. 
Open  wound-treatment  after  amputation,  67, 

69. 
Operating  bag,  25. 
Oral  cavity,  96. 

Orchitis,  tuberculous,  165,  299. 
Organization  of  blood-clot,  5,  6,  12. 
Osteomyelitis,  acute  infectious,  205. 
Otis's  urethrometer,  339. 
Ovarian  tumors,  147. 

Palliative  excision  of  tumors,  53. 
Palmar  bursa,  246. 
suppuration,  247. 
Passive  movements,  75. 


Passive  movements  after  joint  exsection,  307. 
Pasteboard  splints,  311,  312. 
Patella,  suturing  of  fractured,  SO. 
Patterns  for  dressings,  14. 
Perineoplasty,  94. 
Perinephritic  abscess,  276. 
j    Peritonaeum,  denudation  of,  120. 

drainage  of,  121. 

great  absorbing  power  of,  119. 

protection  of,  141. 

stagnant  blood-serum  in,  120. 
Peritoneal    irritation,    saline    purgatives    in, 
121. 

tuberculosis,  1 22. 
Peritonitis  after  abdominal  section,  120. 
Perityphlitic  abscess,  260,  266. 

anterior  parietal  type,  268. 

mesocoeliac  type,  271 

posterior  parietal  type,  270. 

rectal  type,  271. 

Willard  Parker's  type,  267« 
Pes  valgus,  88. 
Phelps's  operation,  88. 
Phlegmon,  cause  of,  183. 

cutaneous,  199. 

development  of,  191. 

retro-pharyngeal,  229. 

subcutaneous,  199. 

subfascial,  203 

treatment  of,  198. 
Phlegmonous  erysipelas,  204. 
I    Plastic  operations,  91. 

on  extremities,  Maas's  method,  94. 
Pleurisy,  purulent,  240. 
Pneumogastric  nei've,  cutting  of,  60. 
Pneumouia,  from  tether,  156,  157,  165. 
Poulticing  in  phlegmon,  consequences  of,  194, 

248. 
Predisposition  to  tuberculosis,  295. 
Prepatellary  bursa,  256. 
Prevesical  abscess,  269. 
Primary  induration,  syphilitic,  353. 

ulcer,  syphilitic,  354. 
Proctoplasty,  288. 
Prostatic  syringe,  Ultzmann's,  338. 
Protection  of  patient's  body  from  wetting,  20. 

of  surgeon's  person,  20. 
Pseudo-erysipelas,  290. 
Ptomaines,  4,  192. 
Puncture  of  abdominal  tumors,  144. 
Purse-string  suture,  131. 
Putrescence,  bacilli  of,  185. 
Pyaemia,  196. 
Pyonephrosis,  279. 


364 


INDEX. 


Quadriceps,  bursa  of,  257,  320. 
Quilled  suture,  146. 
Quinsy  sore  throat,  229. 

Radical  operation  for  hernia,  133. 

for  hydrocele,  163. 

for  varicocele,  164. 
Rectal  cancer,  Kraske's  operation  for,  173. 

tampon-tube,  168,  170. 
Rectum,  aseptics  of,  167. 

extirpation  of,  171. 
Retention  of  sweet  serum  in  freshly  healed 

wounds,  23. 
Retractors,  40. 

Retrograde  catheterism  of  oesophagus,  154. 
Retro-peritoneal  abscess,  260. 
Retro-pharyngeal  abscess,  229. 
Retro-visceral  interspace,  222. 
Revision  for  tuberculosis,  304. 
Rose's  position  of  head,  227. 
Rubber  tissue,  12,  13. 

Sawdust,  16. 

Saws,  disinfection  of,  65. 

Scalp  wounds,  32. 

Scalpels,  shape  of,  37. 

Schede's  dressing,  12,  217. 

Scrofula,  299. 

Secondary  haemorrhage,  8,  49,  72. 

from    perforation    of    popliteal    vein    and 
artery,  259. 
Secondary  suture,  46. 
Scpsin,  4. 
Sepsis,  3. 

Septic  embolism,  195. 
Septic  fever,  191,  193. 
Sequestrum,  diagnosis  of,  210. 
Shock  after  laparotomy,  153. 
Shoulder-joint,    curing    habitual    dislocation 
of,  8. 

curing  irreducible  dislocation  of,  83. 

exsection  of,  308. 
Sigmund's  urethral  syringe,  335. 
Silk,  9. 

Silk-worm  gut,  9. 

Sinuses  after  operations,  their  true  cause,  47. 
Soiled  accidental  wounds,  31. 
Solutions  for  disinfection,  10. 
Small  wounds  the  school  for  asepticism,  23. 
Spanish  windlass,  30. 
Splints  of  pasteboard,  311. 
Sponge  packing,  disadvantage  of,  43. 
Sponges,  8, 

in  laparotomy,  141. 


Spray-apparatus,  141. 
Staphylococcus,  183,  184. 
Starcke's  irrigation-tube,  249,  250. 
Sterilization,  chemical,  7. 
Strangulated  hernia,  123. 
Strangulating  hernial  band,  124. 
Streptococcus,  184,  289. 
Stricture,  urethral,  339. 

incipient,  341. 

permanent  or  cicatricial,  341,  342. 
Stump,  management  of,  after  amputation,  74. 
Styptic  solutions,  abuse  of,  244. 
Submaxillary  capsule,  222,  23J. 
Suction  lead,  46. 
Suppuration,  cause  of,  183. 

cutaneous  and  subcutaneous,  199. 

spread  of,  193. 

superficial,  199. 
Suppurations  on  the  face,  223. 

of  the  fauces,  225. 
Surgical  kidney,  279. 
Suspension,  vertical,  in  phlegmon  of  hand  or 

arm,  249. 
Suture,  abdominal,  146. 

of  anal  fistula,  286. 

secondary,  46. 
Sutures,  8,  44. 

removal  of,  22. 
Suturing  fractured  patella,  SO. 
Syphilitic  external  lesions,  353. 
Syphilitic  ulcer,  caustic  treatment  of,  357. 

primary,  356. 

moist  treatment  of,  356. 

treatment  by  the  actual  cautery  of,  358. 
Syringing  of  freshly  healed  wounds  reprehen- 
sible, 23. 

T-bandage,  169,  170. 

T-splint,  Volkmann's,  77. 

T-tube,  178. 

Tampon  cannula,  Gerster's,  97,  99. 

Tampon-tube,  rectal,  168,  170. 

Temporary  care  of  accidental  wounds,  29. 

Tendinous  sheaths,  tuberculosis  of,  301. 

Teratoma  of  occiput,  106. 

Testis,  necrosis  of,  166. 

removal  of,  165. 
Thiersch's  solution,  10. 

spindle-apparatus,  43. 
Thomas's    operation    for    mammary  tumors, 

114. 
Thoracic  fistula,  242. 

Thrombosis  and  embolism  after  amputation 
of  breast,  118. 


INDEX. 


365 


Thrombosis  of  pulmonary  artery,  118,  141. 

of    innominate    and    axillary   veins    after 
breast  -amputation,  118. 
Thrombosis,  septic,  195. 
Through-drainage,  47. 
Thumb,  suppuration  of,  246, 
Toilet,  abdominal,  145. 
Tongue,  97. 
Tonsillar  abscess,  229. 
Tonsillitis,  225. 
Tonsils,  cauterization  of,  227. 
Tracheotomy,    accidents   in   and   after,   102- 
104. 

apncea  after,  104. 

for  removal  of  foreign  bodies,  106,  107. 

for  goitre,  113. 

avoidance  of  haemorrhage  in,  102. 

inferior,  103. 

for  laryngeal  tumors,  105. 

preliminary,  97,  100. 

statistics  of,  104. 

superior,  102. 
Trendelenburg's      T-shaped      drainage  -  tube, 

178. 
Trocars,  disinfection  of,  7,  76. 
Tuberculosis,  293. 

of  ankle-joint,  325. 

of  bone,  303. 

cutaneous,  298. 

dissemination  of,  295,  318. 

general  treatment  of,  297. 

of  joints,  305. 

of  knee-joint,  319. 

local  treatment  of,  298. 

of  lymphatic  glands,  299. 

of  mucous  membranes,  299. 

of  peritonaeum,  122. 

prevention  of,  299. 

and    pyogenic    infection,    combination   of, 
297. 

of  tendinous  sheaths,  301. 

of  testicle,  165,  299. 
Tuberculous  infection,  direct,  296. 

through  the  lungs,  295. 
Tumors,  extirpation  of,  52,  55. 

treatment  of  pedicle  of  non-ovarian,  56. 


Ulcer  of  leg,  255. 

Ultzmann's  method  of  irrigating  the  neck  of 
the  bladder,  336. 

prostatic  syringe,  338. 

test,  334. 
Uraemia  from  aether,  121. 
Urethral  endoscope,  340. 

injections,  335. 

irrigation,  335. 

stricture,  339,  341,  342. 

syringe,  Sigmund's,  335. 

tuberculosis,  299. 

vegetations,  348. 
Urethritis,  333. 

granular,  348. 
Urethrometer,  Otis's,  339. 
Urethroplasty,  93. 
Urethrotome,  Gerster's,  343. 
Urethrotomy,  external,  346. 

internal,  342. 
Uterine  appendages,  removal  of,  150, 

stump,  152. 

Van  Lennep's  rubber  rings  for  enterorrhaphy, 

162. 
Varicocele,  164. 
Vein,  ligature  of  axillary,  59. 

femoral,  57-59. 

jugular,  60. 
Veins,  exsection  of,  58. 

lateral  closure  of,  56. 

management  of,  in  operative  wounds,  43, 
57,  69,  72. 
Venereal  vegetations,  urethral,  348. 
Vermiform  appendix,  260. 
Vertical  suspension  of  limbs,  249. 
Vesical  tuberculosis,  299. 
Vessels  needed  for  operating,  18. 
Volkmann's  hip-rest,  131. 

multiple  puncturing,  200. 

suspension  splint,  249. 

T-splint,  77. 

White  swelling,  305. 
Wounds,  funnel-shaped,  41. 
bottle-shaped,  41. 


THE   END. 


*^*The  Books  advertised  in  this  List  are  commonly  for  sale  by  hooJcsellers 
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tised price. 


CATALOGUE 

OF 

MEDICAL   WOEKS. 


BARKEKo      On  Sea-Sickness.      By  Foedtce  Barker,  M.  D.      16ino, 
36  pages.     Flexible  cloth,  75  cents. 

Eeprinted  from  the  "  New  York  Medical  Journal."  By  reason  of  the  great  demand  for  the  number 
of  that  Journal  containing  the  paper,  it  is  now  presented  in  book  form,  with  such  prescriptions  added 
as  the  author  has  found  useful  in  relieving  the  suffering  from  sea-sickness. 


BAKKEB,.  The  Puerperal  Diseases.  Clinical  Lectures  delivered  at 
Bellevue  Hospital.  By  Fordtce  Barker,  M.  D.,  Clinical  Professor  of 
Midwifery  and  the  Diseases  of  Women  in  the  Bellevue  Hospital  Medical 
College  ;  late  Obstetric  Physician  to  Bellevue  Hospital ;  Surgeon  to  the 
New  York  State  Woman's  Hospital,  etc.  Fourth  edition.  8vo,  526  pages. 
Cloth,  $5.00  ;  sheep,  $6.00. 

"For  nearly  twenty  years  it  has  been  my  duty,  as  well  as  my  privileafe,  to  give  clinical  lectures  at 
Bellevue  Hospital  on  midwifery,  the  puei-peral  and  the  other  diseases  of  women.  This  volume  is  made 
up  substantially  from  phonographic  reports  of  the  lectures  which  I  have  given  on  the  puerperal  diseases. 
Having  had  rather  exceptional  opportunities  for  the  study  of  these  diseases,  I  have  felt  it  to  be  an  im- 
perative duty  to  utilize,  so  far  as  lay  in  my  power,  the  advantages  which  I  have  enjoyed  for  the  pro- 
motion of  science,  and,  I  hope,  for  the  interests  of  humanity." — ^rom  AutTior's  Preface. 


BARTHOLOW.    A  Treatise  on  the  Practice  of  Medicine,  for  the 

Use  of  Students  and  Practitioners.  By  Roberts  Bartholovt,  M.  A., 
M.  D.,  LL.  D.,  Professor  of  Materia  Medica  and  General  Therapeutics  in 
the  Jefferson  Medical  College  of  Philadelphia  ;  recently  Professor  of  the 
Practice  of  Medicine  and  of  Clinical  Medicine  in  the  Medical  College  of 
Ohio,  in  Cincinnati,  etc.  Seventh  edition,  revised  and  enlarged.  8vo. 
Cloth,  $5.00  ;  sheep  or  half  russia,  16.00. 

The  same  qualities  and  characteristics  which  have  rendered  the  author's  "  Treatise  on  Materia  Medica 
and  Therapeutics  "  so  acceptable  are  equally  manifest  in  this.  It  is  clear,  condensed,  and  accurate.  The 
Whole  work  is  brought  up  on  a  level  with,  and  incorporates,  the  latest  acquisitions  of  medical  science, 
and  may  be  depended  on  to  contain  the  most  recent  information  up  to  the  date  of  publication. 


D.  APPLETO^  &   CO:S  ILLUSTRATED 


"  The  large  number  of  readers  who  are  already 
familiar  with  this  work  will  be  i?iaJ  to  learn  that 
the  present  edition  has  been  care/ully  revised  by 
the  author,  considerably  enlar<red,  and  is  intended 
to  include  all  tliat  has  in  the  most  recent  period 
been  allied  to  practicid  medicine,  especially  in  its 
clinical  horizon.  Tiie  author  felicitates  himself  on 
the  lar<re  sales  obtained  fur  the  previous  editions, 
and  there  is  no  reason  why  the  present  one  should 
not  continue  to  j^ain  in  the  opinion  of  many. 
What  doubtle-s  lends  the  volume  one  of  its  special 
attractions  to  these  is  the  authoritative  expressions 
which  are  frequent  in  its  pages  on  subjects  where 


Ascaris  lumbrieoides. — 1.  complete  worm  ;  2.  heaii;  3, 
tail  of  the  male ;  4,  middle  of  the  body  of  female. 

the  reader  might  be  left  in  uncertainty  elsewhere. 
This  remark  applies  both  to  pathology  and  treat- 
ment. The  fullness  with  which  therapeutics  are 
taught  stands  in  noteworthy  contrast  to  the  ma- 
jority of  treatises  on  practice.  This,  too,  is  un- 
doubtedly a  feature  which  will  be  agreeable  to 
numerous  purchasers.  Some  seeming  excess  of 
conciseness  in  certain  portions  is  explained  by  the 
fact  that  this  is  but  one  volume  of  a  series  proposed 
by  the  author,  which  will  cover  the  whole  domain 
of  special  pathology  and  therapeutics.'' — Medical 
and  Surgical  Reporter. 

"That  six  editions  of  such  a  work  should  be 
called  for  in  six  years  is,  perhaps,  the  most  flatter- 
ing testimonial  that  a  book  can  receive,  and  must 
outweigh  every  other  comment,  favorable  or  un- 


favorable. In  the  preface  to  this  edition  is  an 
announcement  which  will  be  welcomed  bv  all  of 
Dr.  Bartholow's  numerous  admirers,  namely,  that 
he  has  now  in  preparation  another  work  on  the 
'  Principles  of  Medicine'  which,  together  with  the 
one  under  review,  and  his  '  Materia  Medica  and 
Therapeutics,'  shall  constitute  a  trio  of  volumes, 
each  containing  matter  complementary  to  the 
others.  Certainly  three  such  volumes  must  con- 
stitute a  monument  which  will  render  the  writer's 
fame  almost  undying." — Medical  Irtss  of  Western 
^ew  York. 

"  Professor  Bartholow  announces  in  the  preface 
of  this  edition  his  intention  of  preparing  a  work 
in  three  volumes  which  shall  cover  the  whole  do- 
main of  special  pathology  and  therapeutics.  The 
volume  on  'Materia  Medica'  appeared  some  time 
ago,  but  the  third  volume,  which  will  treat  of  the 
'Principles  of  Medicine,'  is  now  in  course  of  care- 
ful preparation,  and  will,  when  published,  complete 
a  most  valuable  set.  The  present  edition  of  Pro- 
fessor Bartholow's  '  Practice  '  is  considerably  larger 
than  tlie  last,  several  new  subjects  having  teen  m- 
troduced,  together  with  numerous  new  illustrations. 
It  is  deservedlv  popular  with  practitioners  and 
students,  and  likely  ere  long  to  become  one  of  the 
standard  works  on  j^ractice,  if  it  ha.s  not  already 
attained  this  position." — Facijie  Medical  and  Sur- 
gical Journal  and  WeJ>tern  Lancet. 

"  The  deserved  popularity  of  this  work  is  at- 
tested by  the  fact  that  the  first  edition  was  is.sued 
in  ISSO,  that  a  second  was  demanded  in  three 
months,  and  that  the  others  have  followed  them  in 
rapid  succession  and  been  met  by  appreciative 
students  always.  The  author  says  in  liis  preface 
to  this  edition  that  he  has  sought  to  make  it  worthy 
of  the  approbation  of  his  readere  by  increasing  the 
practical  resources  of  his  work,  devoting  his  atten- 
tion chiefly  to  the  clinical  aspects  of  medicine, 
without  overlooking  the  advances  made  in  tiie 
scientific  branch.  Tliis  book,  like  the  previous 
editions  of  the  work,  is  the  product  of  a  master 
and  an  honored  authority,  and  in  its  new  form, 
with  such  of  the  late.st  ideas  as  the  author  can 
conscientiously  indorse  or  present  for  considera- 
tion, continues  to  hold  its  place  among  the 
standard  text-books  on  all  matters  included  in  it." 
— Ji'orth  Carolina  Medical  Journal. 

"  This  valuable  work  appears  in  its  sixth  edi- 
tion considerably  enlarged,  and  improved  materi- 
ally in  many  respects.  Tne  arrangement  of  the 
subjects  appears  to  be  pretty  much  the  same  as  in 
former  editions,  and  the  description  of  diseases  is 
also  little  modified.  Some  new  chapters  have  been 
added,  however,  and  new  subjects  introduced, 
making  the  volume  completely  cover  the  entire 
domain  of  practice,  without  anything  superfluous. 
Considering  the  immense  scope  of  subjects,  the 
directness  of  statement,  and  the  plain,  terse  man- 
ner of  dealing  with  the  phenomena  of  disease,  this 
practical  work  has  no  counterpart." — Kansas  City 
Medical  Record. 


BARTHOLOW.  On  the  Antagonism  between  Medicines  and 
between  Remedies  and  Diseases.  Being  the  Cartwright  Lectures 
for  the  Year  1880.  By  Roberts  Bartholow,  M.  A.,  M.  D.,  LL.  D.,  Pro- 
fessor of  Materia  Medica  and  General  Therapeutics  in  the  Jefferson 
Medical  College  of  Philadelphia,  etc.,  etc.     8vo.     Cloth,  $1.25. 

"  We  are  glad  to  possess,  in  a  form  convenient     deductions  of  a  careful  and  accomplished  observer, 

regardincr  the  applications  of  this  knowledge  to  dis- 


for  reference,  this  most   recent  summary  of  the 
physiological  action  of  important  remedies,  with  the 


eased  states." — College  and  Clinical  Record. 


CATALOGUE   OF  MEDICAL   WORKS. 


"There  are  few  writers  who  have  taken  the 
trouble  to  compile  the  lucubrations  of  the  multitude 
of  scribblers  who  find  a  specific  in  every  drug  they 
happen  to  prescribe  for  a  self-limited,  non-malig- 
nant disease  ;  and  fewer  who  can  detect  the  trashy 
chaff  and  garner  only  the  ripe,  plump  grains. 
This  Bartholow  has  done,  and  no  one  is  more  ripe, 
nor  better  qualified  for  this  herculean  task ;  and, 
the  best  of  all  is,  condense  it  all  in  his  antago- 
nisms. No  one  can  peruse  its  pregnant  pages 
without  noticing  the  painstaking  research  and 
large  collection  of  authorities  fi-om  which  he  has 
drawn  his  conclusions.  The  practitioner  who  pur- 
chases these  antagonisms  will  find  himself  better 
qualified  to  cope  with  the  multifarious  maladies 
after  its  careful  perusal." — Indiana  Medical  Re- 
porter. 

"The  criticisms  made  upon  these  lectures  have 
invariably  been  most  favorable,  the  topic  itself  is 
one  of  the  most  interesting  in  the  entire  range  of 
medicine,  and  it  is  treated  of  by  the  accomplished 
author  in  a  most  scholarly  manner.  Dr.  Bartholow 
worthily  ranks  as  one  of  the  best  writers,  while  at 
the  same  time  one  of  the  most  diligent  workers,  in 
the  medical  field  in  all  America,  and  there  can  be 
no  doubt  that  this,  his  latest  contribution  to  medi- 
cal science,  will  add  materially  to  his  previously 
high  reputation.    Much  profit,  no  little  pleasure, 


and  material  assistance  in  the  solution  of  many 
therapeutical  problems  are  to  be  obtained  from  a 
perusal  of  these  lectures.  The  author  has  done 
wisely  and  conferred  a  boon  by  permitting  their 
publication  in  the  present  book-form,  and  we  are 
satisfied  it  will  be  extensively  asked  for,  and  just 
as  extensively  read  and  appreciated."— 6'ar(aa?a 
Medical  and  Surgical  Journal. 

"  It  will  be  observed  that  the  scope  of  the  work 
is  extensive,  and,  in  justice  to  the  author,  not  only 
is  the  extent  of  this  indicated,  but  the  character  of 
it  is  also  furnished.  No  one  can  read  the  synopsis 
given  without  being  impressed  with  the  importance 
and  diversity  of  the  subjects  considered.  Indeed, 
most  of  the  important  forces  in  therapeutics  and 
materia  medica  are  herein  stated  and  analyzed." — 
American  Medical  Bi-  Weekly. 

"  Probably  most  of  our  readers  will  consider 
that  we  have  awai'ded  this  treatise  high  praise 
when  we  say  that  it  seems  to  us  the  most  carefully 
written,  best  thought-out,  and  least  dogmatic  work 
which  we  have  yet  read  from  the  pen  of  its  author. 
It  is  indeed  a  very  praiseworthy  book ;  not  an 
original  research,  indeed,  but,  as  a  resume  of  the 
world's  work  upon  the  subject,  the  best  that  has 
hitherto  been  published  in  any  language." — 
Philadelphia  Medical  Times. 


BARTHOIjOW.     Treatise  on  Materia  Medica  and  Therapeutics. 

By  Roberts  Bartholow,  M.  A.,  M.  D.,  LL.  D.,  Professor  of  Materia 
Medica  and  Therapeutics  in.  the  Jefferson  Medical  College  ;  formerly 
Professor  of  the  Theory  and  Practice  of  Medicine,  and  of  Clinical 
Medicine,  and  Professor  of  Materia  Medica  and  Therapeutics  in  the 
Medical  College  of  Ohio,  etc.  Seventh  edition,  revised  and  enlarged. 
8vo.     Cloth,  15.00  ;  sheep,  $6.00. 


The  following  are  notices  of  the  sixth  edition . 


"  The  very  best  evidence  of  the  success  of  a 
work  is  the  continuous  and  increasing  demand  for 
it.  Bartholow's  '  Materia  Medica  and  Therapeu- 
tics' has  followed  this  course  since  the  appearance 
of  the  first  edition,  in  June,  1876,  and  has  com- 
pelled the  publishers  to  again  place  before  the  pro- 
fession the  sixth  edition.  In  this  issue  of  the  work 
the  author  has  revised  the  former  edition  most 
carefully,  and  has  included  in  its  pages  the  latest 
and  the  most  valuable  remedies.  About  one  hun- 
dred pages  have  thus  been  added  to  this  valuable 
work,  tlie  new  contributions  having,  as  the  author 
states,  been  assigned  to  places  according  to  their 
physiological  relations.  The  many  additions,  just 
referred  to,  can  only  be  observed  by  a  careful  ex- 
amination of  all  parts  of  the  book.  .  .  .  The  work 
is  not  only,  as  in  fonuer  editions,  well  arranged, 
but  is  the  most  progressive  one  of  all  those  now 
before  the  profession,  in  the  thorough  consideration 
of  all  therapeutic  measures  of  value  in  the  treat- 
ment of  disease." — Medical  Register. 

"Since  1876  this  work  has  passed  through  six 
editions,  a  degree  of  favor  which  is  seldom  ac- 
corded to  medical  works.  .  .  .  We  have  written  in 
former  issues  of  the  Journal  our  appreciation  of 
this  volume,  and  we  take  this  occasion  to  say  that 
we  consider  it  essential  to  every  well-selected 
library." — North  Carolina  Medical  Journal. 


"  It  is  to  be  naturally  assumed  that  the  appear- 
ance of  six  editions  of  tliis  work  in  a  period  of  a 
little  more  than  eleven  j^ears  is  an  indication  of 
the  measure  of  appreciation  in  which  it  is  held  by 
the  profession.  .  .  .  The  author's  additions  have 
been  extensive  and  important,  and  give  increased 
value  to  a  work  that  is  already  recognized  as  oc- 
cupying a  very  conspicuous  place  in  the  medical 
literature  of  the  day." — College  and  Clinical 
Record. 

"  Since  Bartholow's  '  Materia  Medica'  appeared 
eleven  years  ago,  its  several  editions  have  occupied 
a  place  of  which  its  author  may  well  feel  proud. 
In  the  present  edition  we  find  much  new  matter, 
which,  taken  as  a  whole,  adds  nearly  one  hundred 
pages.  The  '  Clinical  Index,'  which  contributes 
greatly  to  the  value  of  the  book,  has  been  retained. 
But  few  books  become  so  popular  as  Bartholow's 
'  Materia  Medica.'  " — Practice. 

"Bartholow's  'Materia  Medica'  is  a  book  too 
well  known  to  the  practitioners  of  medicine  to 
need  at  this  day  any  review.  .  .  .  Unquestionably 
the  new  edition  is  a  great  improvement  on  the  old 
one;  and  even  if  nothing  were  added  but  a  sum- 
mary statement  about  new  remedies  in  use  since 
the  last  edition  J  the  work  w 
Gaillard's  Medical  Journal. 


D.  APPLETOX  &    CO:S  ILLUSTEATED 


BASTIAN.  Paralyses :  Cerebral,  Bulbar,  and  Spinal.  A  Manual 
of  Diagnosis  for  Students  and  Practitioners.  By  H.  Charlton  Bastian, 
M.  A.,  M.  D.,  F.  R.  S.  ;  Fellow  of  the  Royal  College  of  Physicians  ;  Ex- 
aminer in  Medicine  at  the  Royal  College  of  Physicians  ;  Professor  of 
Clinical  Medicine  and  of  Pathological  Anatomy  in  University  College, 
London,  etc.    With  136  Illustrations.    Small  8vo,  671  pages.    Cloth,  84.50. 


"  The  work  is  designed  to  facilitate  diagnosis  of 
the  various  forms  of  paralysis.  .  .  .  The  book  sup- 
plies a  want  Ions  felt ;  to  come  from  this  celebrated 
author  makes  it  much  more  valuable." — Buffalo 
Medical  and  Surgical  Journal. 

'•  We  deem  the  work  to  be  one  of  immense  value 
which  must  add  greatly  to  its  author  s  already  large 
reputation,  and  we  are  heartily  glad  to  see  it  repro- 
duced by  an  American  publishing  house." — Medi- 
cal Press  of  Western  Seic  York. 

"  Throughout  the  work  the  author's  mastery  of 
the  subject  is  constantly  apparent,  and  it  must  take 
rank  as  without  a  superior  in  its  special  depart- 
ment."— Medical  and  Surgical  Reporter. 

"This  is  'a  manual  of  diagnosis  for  students 
and  practitioners,'  and  as  a  special  work  on  the  di- 
agnosis on  locahzation  of  a  paralyzing  lesion  we  do 
not  know  of  its  equal  in  any  language." —  Virginia 
Medical  Monthly. 

"■  We  can  strongly  recommend  Dr.  Bastian's 
work  to  the  student  and  practitioner  as  a  monu- 
ment of  learning  exceedingly  well  put  together." 
— Lancet. 


"  For  diagnosis  Bastian's  work  will  take  the 
highest  rank.  It  is  remarkable  for  its  philosophi- 
cal tone  and  for  the  author's  critical  comments 
on  numerous  obscure  problems  on  neurology." — 
Am-erican  Journal  of  the  Medical  Sciences. 

"  The  book  is  devoted  to  the  study  of  the  diag- 
nosis of  paralysis,  and  its  declared  purpose  is  to 
aid  the  physician,  when  brought  face  to  face  with  a 
case  of  central  nervous  trouble  resulting  in  pa- 
ralysis, to  locate  the  seat  of  the  lesion  and  the 
probable  extent  of  the  trouble.  It  fills  a  space  in 
this  department  of  medical  literature  not  hereto- 
fore taken  up  by  any  author  with  such  definite 
limits,  and  its  merit  is  equal  to  the  author's  repu- 
tation."— ^'orth  Carolina  Medical  Journal. 

"  In  unfolding  this  great  theme,  the  author  not 
only  sets  forth  with  care  the  symptomatology  of 
the"  afiections  in  hand,  but  passes  in  review  all 
essential  factors  in  the  anatomy,  ph^■siology,  and 
pathologv  of  the  nervous  system.  'The  reader  of 
this  wort  will  find  many  points  hitherto  obscure 
in  diagnosis  made  clear,  and  in  practice  will  be 
able  to  rest  his  prognosis  and  treatment  in  not  a 
few  of  the  fonns  of  paralysis  upon  a  firmer  scien- 
tific basis." — American  Practitioner  and  News. 


BASTIAN.  Paralysis  from  Brain  Disease  in  its  Common 
Forms.  By  H.  Chaeltox  Bastian^,  M.  A.,  M.  D.,  Fellow  of  the  Royal 
College  of  Physicians  ;  Professor  of  Pathological  Anatomy  in  Uni- 
versity College,  London.  With  Illustrations.  12mo,  340  pages.  Cloth, 
ei.T5.' 

"  These  lectures  were  delivered  in  University  College  Hospital  last  year,  at  a  time  when  I  was  doing 
duty  for  one  of  the  senior  physicians,  and  during  tlie  same  year — afterthey  had  been  reproduced  from 
very  full  notes  taken  by  my  friend  Mr.  John  Tweedy — they  appeared  in"  the  pages  of  '  The  Lancet.' 
They  are  now  republished  at  the  request  of  many  friends,  though  only  after  having  undergone  a  very 
earetul  revision,  during  which  a  considerable  quantity  of  new  matter  has  been  added.  It  would  have 
been  easy  to  have  very  much  increased  the  size  of  the  book  by  the  introduction  of  a  larger  number  of 
illustrative  cases,  and  by  treatment  of  many  of  the  subjects  at  greater  lensrth,  but  this  the  author  has 
purposely  abstained  from  doing  under  the  belief  that  in  its  present  form  it  is  likely  to  prove  more  ac- 
ceptable "to  students,  and  also  perhaps  more  useful  to  busy  practitioners." — Extract  from  Preface. 


BASTLAN.  The  Brain  as  an  Organ  of  Mind.  By  H.  Charlton 
Bastiax,  M.  a.,  M.  D.,  Fellow  of  the  Royal  College  of  Physicians  ;  Pro- 
fessor of  Pathological  Anatomy  in  University  College,  London.  With 
184  Illustrations  and  an  Index.     12mo,  708  pages.     Cloth,  $2.50. 


"  This  work  is  the  'best  book  of  its  kind.  It  is 
full,  and  at  the  same  time  concise ;  comprehensive, 
but  confined  to  a  readable  limit ;  and,  though  it 
deals  with  many  subtile  subjects,  it  expounds  them 
in  a  style  whict  is  admirable  for  its  clearness  and 
simpUcity." — Xature. 

"  The  fullest  scientific  exposition  yet  published 
of  the  views  held  on  the  subject  of  psychology  bv 
the  advanced  physiological  school.  It  teems  with 
new  and  suggestive  ideas." — London  Athenceum. 


"  Dr.  Bastian's  new  book  is  one  of  great  value 
and  importance.  The  knowledge  it  gives  is  univer- 
sal in  its  claims,  and  of  moment  to  everybody.  It 
should  be  forthwith  introduced  a*  a  manual  into  all 
colleges,  high  schools,  and  normal  schools  in  the 
country ;  not  to  be  made  a  matter  of  ordinary  me- 
chanical recit.itions,  but  that  its  subject  may  arrest 
attenrion  and  rouse  interest,  and  be  lodged  in  the 
minds  of  students  in  connection  with  observations 
and  experiments  that  will  give  reality  to  the  knowl- 
edge required." — Popular  Science  Monthly. 


CATALOGUE  OF  MEDICAL  WORKS. 


BENNET.     On  the  Treatment  of  Pulmonary  Consumption,  by 

Hygiene,  Climate,  and  Medicine,  in  its  Connection  with  Modem  Doctrines. 
By  James  Henry  Bennet,  M.  D.,  Member  of  the  Royal  College  of 
Physicians,  London  ;  Doctor  of  Medicine  of  the  University  of  Paris,  etc., 
etc.     Thin  8vo,  190  pages.     Cloth,  I1..50. 

An  interesting  and  instructive  work,  written  in  the  strong,  clear,  and  lucid  manner  which  appears  in 
all  the  contributions  of  Dr.  Bennet  to  medical  or  general  literature. 

"  We  cordially  commend  this  book  to  the  atten-     temperate   climates,  pulmonary   consumption."— 
tion  of  all,  for  its  practical,  common-sense  views     Detroit  Review  of  Medicine. 
of  the  nature  and  treatment  of  the  scourge  of  all 

BENNET.  Winter  and  Spring  on  the  Shores  of  the  Mediter- 
ranean ;  or,  the  Genoese  Rivieras,  Italy,  Spain,  Corfu,  Greece,  the  Archi- 
pelago, Constantinople,  Corsica,  Sicily,  Sardinia,  Malta,  Algeria,  Tunis, 
Smyrna,  Asia  Minor,  with  Biarritz  and  Arcachon,  as  Winter  Climates. 
By  James  Henry  Bennet,  M.  D.,  Member  of  the  Royal  College  of 
Physicians,  London,  etc.,  etc.  Fifth  edition.  With  numerous  Illustra- 
tions and  Maps.     12rao,  655  pages.     Cloth,  18.50. 

This  work  embodies  the  experience  of  fifteen  winters  and  springs  passed  by  Dr.  Bennet  on  the 
shores  of  the  Mediterranean,  and  contains  much  valuable  information  for  physicians  in  relation  to  the 
health-restoring  climate  of  the  regions  described. 

"  We  commend  this  book  to  our  readers  as  a  is  at  once  entertaining  and  instructive."— i\^«io 
volume  presenting  two   capital    qualifications — ^it     iork  Medical  Journal. 

BILLINGS.  The  Relation  of  Animal  Diseases  to  the  Public 
Health,  and  their  Prevention :  With  a  Brief  Historical  Sketch  of 
the  Development  of  Veterinary  Medicine,  from  the  Earliest  Ages  to  the 
Present  Time  ;  and  a  Critical  Historical  Sketch  of  the  Leading  Schools  of 
the  World,  showing  the  Reasons  which  led  to  their  Foundation,  and  with 
the  Endeavor  to  draw  from  their  Experiences  Teachings  of  Value  toward 
the  Establishment  of  a  General  Veterinary  Police-hygienic  System  and 
Veterinary  Schools  in  this  Country.  By  Frank  S.  Billings,  Veterinary 
Surgeon,  Graduate  of  the  Royal  Veterinary  Institute,  Berlin  ;  Member  of 
the  Royal  Veterinary  Association  of  the  Province  of  Brandenburg, 
Prussia  ;  Honorary  Member  of  the  Veterinary  Society  of  Montreal,  Can- 
ada, etc.,  etc.     8vo.     Cloth,  $4.00. 

"  This  is  the  great  health-book  of  Dr.  Frank  S.  very  least  should  be  in  the  libraries  of  every  na- 

Billings,  and  it  is  not  too  much  to  promise  that  a  tional.   State,   city,   town,   and   county  Board    of 

study  and  observance  of  its  teachings,  that  are  the  Health.     It  certainly  should  be  studied  by  every 

results  of  actual  experiments,  will  work  a  revolu-  teacher  and  scientific  practitioner  of  veterinary 

tion  in  the  sanitary  condition  of  the  United  States,  medicine,  and  will  be  of  great  service   to   ev^ery 

...  It  is  a  work  for  all  stock-breeders  and  for  all  great  stock  and  cattle  holder  and  dealer.  ...  It 

families." — Louisville  Courier- Journal.  is  evidently  written  by  a  man  of  great  ability  and 

,,rm-  •  4.1,  i-ii  V  1  •  i.  •  ..  ^1  high  culture,  well  versed  both  in  the  literature  and 
This  IS  the  title  of  a  work  .lust  given  to  the  ^^^^^^  ^^  ^^j^  ^^  ^j^^  practical  bearings  of  his  sub- 
world,  and  m  its  pages  subjects  ot  vital  mterest  -3^^.  Such  a  man  has  a  great  and  inalienable  right 
are  treated  of  m  a  lucid  and  perspicuous  manner  \^  ^^^^  opinions  of  his  oin  ;  and  he  has  them,  and 
•  •  ■  .h  y^ell- established  statements  should  ^^es  not  hesitate  to  express  them.  .  .  .  We  hope 
arouse  the  public  feelmg  to  provide  that  boards  of  ^^^  ^^jj^^^  ^^^^  ^^^  ^\^^^^^  ^^^1  ^^  received  bv 
health  should  be  caretul  and  efficient  m  the  exer-  ^n,  except  perhaps  bv  those  especially  attacked, 
cise  ot  their  duties  as  also  that,  as  individuals,  ^^,-^^^  ^^^  ^^^^  welcome  that  its  author  and  pub- 
every  one  should  labor  t^  take  good  care  ot  him-  15,^^^.^  ^^^^  ^^^^^  ^^^  i^_  j^  ^^n  ^ake  its  stand 
^^^^^i^.^^'^^^y'  ^^d  ^is  domestic  animals."-i\'e«;  alongside  of  the  popular  treatises  of  Hilliard  and 
or       tmes.  Eobertson,  and  on  all  purely  scientific  matters  will 

"  This  handsome  volume  does  great  credit  to  lead  them.     Either  of  these  works,  together  with 

its  author  and  publishers      It  is  an  excellent  book  Dr.  Billings's,  will  make  almost  a  complete  Ubraiy 

m  most  respects,  an  extraordinary  one  in  many,  on  veterinary  medicine." — Journal  of  Comparative 

and  an  objectionable  one  in  very  few.     It  at  the  Medicine  and  Surgery. 


6 


D.  APPLETON  &    CO:S  ILLUSTRATED 


BILLROTH.     General  Surgical  Pathology  and  Therapeutics,  in 

Fifty-one  Lectures.  A  Text-Book  for  Students  and  Physicians.  By  Dr. 
Theodor  Billroth,  Professor  of  Surgery  in  Vienna.  With  Additions  by 
Dr.  Alexander  von  Winiwarter,  Professor  of  Surgery  in  Liittich.  Trans- 
lated from  the  fourth  German  edition  with  the  special  permission  of  the 
author,  and  revised  from  the  tenth  edition,  by  Charles  E.  Hackley,  A.  M., 
M.  D.,  Physician  to  the  New  York  and  Trinity  Hospitals  ;  Member  of  the 
New  York  County  Medical  Society,  etc.  8vo,  835  pages.  Cloth,  $5.00  ; 
sheep,  $6.00. 


SpEctMEN  OF  Illustration. 


«'^C0 


@ 


•>©;;- vk 


O/e.  oq  Qrt,  C!i;o    ki  oiiv^ 


Tissue  of  a  glio  sarcoma  after  Yirchow.    Magnified 
350  diameters. 


"  Since  this  translation  was  revised  from 
the  sixth  German  edition  in  1874,  two  other 
editions  have  been  published.  The  present 
revision  is  made  to  correspond  to  the  eighth 
German  edition. 

"Lister's  method  of  ajitiseptic  treatment 
is  referred  to  in  various  places,  and  other  new 
points  that  have  come  up  within  a  few  years 
are  discussed. 

"  A  chapter  has  been  written  ou  amputa- 
tion and  resection.  In  all,  there  are  seventy- 
four  additional  pages,  with  a  number  of 
woodcuts." — Extract  from  Translator'' s  Pref- 
ace to  the  Revised  Edition. 


"The  want  of  a  book  in  the  English 
language,  presenting  in  a  concise  form  the 
views  of  the  German  pathologists,  has  long 
been  felt,  and  we  venture  to  say  no  book 
could  more  perfectly  supply  that  want  than 
the  present  volume." — The  Lancet. 


BRAMWELL.    Diseases  of  the  Heart  and  Thoracic  Aorta.    By 

Byrom  Bramwell,  M.  D.,  F.  R.  C.  P.  E.,  Lecturer  on  the  Principles  and 
Practice  of  Medicine  and  on  Medical  Diagnosis  in  the  Extra-Academical 
School  of  Medicine,  Edinburgh  ;  Pathologist  to  the  Royal  Infirmary, 
Edinburgh,  etc.  Illustrated  with  226  Wood  Engravings  and  68  Litho- 
graph Plates,  showing  91  Figures — in  all,  317  Illustrations.  Svo,  788 
pages.     Cloth,  $8.00  ;  sheep,  $9.00. 


"  A  careful  perusal  of  this  work  will  well  repay 
the  student  and  refresh  the  memory  of  the  busy 
practitioner.  It  is  the  outcome  of  sound  knowledge 
and  solid  work,  and  thus  devoid  of  all  '  padding,' 
which  forms  the  bulk  of  many  monographs  on  this 
and  other  subjects.  The  material  is  treated  with 
due  regard  to  its  proportionate  importance,  and  the 
author  has  well  und  wisely  carried  out  his  apjiarent 
intention  of  rather  furnishing  a  groundwork  of 
knowledge  on  which  the  reader  must  build  for  him- 
self by  personal  observation,  than  of  making  ex- 
cursions into  the  region  of  dogma  and  of  fancy  by 
which  his  book  might  have  scoured  a  perhaps  more 
rapid  but  certainly  a  more  evanc^cant  success  than 
that  which  it  will  now  undoubtedly  and  deserv- 
edlj'  attain." — Medical  Times  and  Gazette. 

'■'' in  this  elegant  and  profusely  illustrated  vol- 
ume Dr.  Bramwell  has  entered  a  field  which  has 
hitherto  been  so  worthily  occupied  by  British 
duthors — Hope,  Hayden,  Walshe,  and  others ;  and 


we  can  not  but  admire  the  industry  and  cai'e 
which  he  has  bestowed  upon  the  work.  As  it 
stands,  it  may  fairly  be  taken  as  representing 
the  stand-point  at  which  we  have  arrived  in 
cardiac  physiology  and  pathology  ;  for  the  book 
opens  with  an  extended  account  of  physiologi- 
cal facts,  and  especially  the  advances  made  of 
late  years  in  the  neuro-muscular  mechanism  ot 
the  heart  and  blood-vessels.  Although  in  this 
respect  physiological  research  has  outstripped 
clinical  and  pathological  observation.  Dr.  Bram- 
well has,  we  think,  done  wisely  in  so  intro- 
ducing his  treatise,  and  has  thereby  greatly 
added  to  its  value.  A  chapter  upon  tlioracic 
aneurism  terminjites  a  work  which,  from  the  sci- 
entific manner  in  which  the  subject  is  treated, 
from  the  cai-e  and  discrimination  exhibitedj  and 
the  copious  elaborate  illustrations  with  which  it 
is  adorned,  is  one  which  will  advance  the  author's 
reputation  as  a  most  industrious  and  painstaking 
clinical  observer." — Lancet. 


CATALOGUE   OF  MEDICAL   WORKS. 


BRYANT.  A  Manual  of  Operative  Surgery^  By  Joseph  D. 
Betaxt,  M.  D.,  Professor  of  Anatomy  and  Clinical  Sui-gery,  and  Associ- 
ate Professor  of  Orthopsedic  Surgery  in  Bellevue  Hospital  Medical  Col- 
lege ;  Visiting  Surgeon  to  Bellevue  Hospital,  and  Consulting  Surgeon  to 
the  New  York  Lunatic  Asylum  and  the  Out-Door  Department  of  Bellevue 
Hospital.  New  edition,  revised  and  enlarged.  With  793  Illustrations. 
8vo,  530  pages.     Cloth,  85.00  ;  sheep,  86.00. 


"  T'le  apolozy  ariven  by  the  author,  it'  any 
apology  be  needed  for  the  appearance  of  so  ex- 
celleiTt  a  work,  is  the  frequent  request  on  the 
part  of  those  whom  it  has  been  his  pleasure  to 
instruct  in  operative  suro-ery  durincr  the  past 
few  years,  to  make  a  boot  based  somewhat  on 
the  plan  he  has  employed  in  teaehins  this  sub- 
ject. We  have  perused  this  work  with  great 
pleasure  and  profit,  and  can  bear  testimony  to 
the  care  and  attention  which  the  author  has 
bestowed  to  make  the  book  a  benefit  to  his  co- 
workers in  the  same  field.  The  cuts  are 
numerous  and  well  executed,  and  the  text  clear 
and  well  printed.  The  various  operative  pro- 
cedures are  clearly  and  concL>ely  described, 
and  the  results  of  the  various  operations  briefly 
stated.  The  cbapter  on  the  treatment  of 
operation  wounds  is  worthy  of  special  mention. 
The  work  is  fully  abreast  of  the  most  recent 
advances  in  operative  surfers',  and  we  have 
nmch  pleasure  in  recommendiug  it  to  onr 
readers." — Canada  Lancet. 


Specemkjts  of  Illustratioxs. 


"  The  author  of 
thi-  work  seems  to 
know  how  in  the 
bnefest  space  to 
gi\  e  the  student  of 

bur^ery     the      aid  

necessary    ' to    ac-  ^ 

quire     established 

tacts,'  and  this  is  an  important  point  in  a  book  of  this  kind.      The  text  is 

moot  fully  illustrated,  and  brin^  the  subject  to  date,  and  it  will  be  found 

nseful  in  the  sphere  to  which  it  oelongs." — I^ew  York  Medical  Times. 

"  The  work  of  Professor  Bryant,  while  it  does  not  pretend  to  be  a  rival  a 
the  larger  works  or  systems  of  surgery,  is  of  its  kind  a  most  excellent  book. 
Theories  and  doubtful  methods  of  operating  find  no  place  in  the  volume.  It 
ih  lather  to  known  facts  and  established  procedures  that  the  author  has  limited 
his  labor,  and  the  judgment  which  he  evinces  in  selecting  from  the  various 
methods  of  operating  in  surgical  cases  is  crenerally  of  a  most  reliable  r.ature ; 
mdeed.  it  is  this  selecting  from  many  proposed 
procedures,  which  are  usually  met  with  in  the 
larger  surgical  works,  that  much  of  the  value  of 
Professor  Bryant's  book  depends,  and  in  this 
respect  the  book  becomes  a  very  able  aid  to  the 
inexperienced  surgeon.  The  scope  of  the  work 
includes  most  of  the  surgical  diseases,  and  the 
operative  methods  for  their  relief  or  cure.  The 
operations  peculiar  to  the  female  sex,  and  the  sur- 
trery  of  the  eye  and  ear,  are  not  considered  in  the 
book.  ...  In  concluding  our  notice  of  Professor 
Bryant's  book,  it  remains  for  us  to  congratulate 
him  upon  the  successful  result  of  his  labor.  He 
has  written  a  very  able  and  reliable  surgical  work, 
one  that  may  be  consulted  both  by  surgeon  and 
-ludent,  and  one  that  contains  all  the  m.ore  important  advances  of  modern 
-urjery.  The  publishers'  part  of  the  work  has  been  well  done,  and  the 
numerous  illustrations  add  much  to  the  value  of  the  volume." — Thei-ajjeutic 
Gazette. 

•'  The  scope  of  the  above  work  includes  the  methods  of  operating  for  the 
relief  or  cure  of  all  surgical  lesions,  with  the  exception  of  those  peculiar  to 
the  female  sex  and  those  of  the  eye  and  ear.  It  is,  therefore,  seen  that  much 
ground  would  have  to  be  gone  over  if  a  description  of  all  operations  were 
given ;  and,  indeed,  to  describe  all  the  operations  proposed  for  eveiy  surgical 


D.  APPLETON  &    CO:S  ILLUSTRATED 


lesion  would  be  a  laborious  and  useless  task.  The 
plan  adopted  by  Professor  Eryant  has  been  to 
select  such  procedures  tliat  experience  and  judg- 
ment recommend  as  the  best,  and  it  is  in  mak- 
intr  the  selections  that  the  author  lias  tshown  his 
ability  to  write  a  jjood  book.  Not  only  liave 
there  been  shown  unusually  good  discriminating 
powers  in  the  choice  of  selecting  the  various 
methods,  but  the  views  of  the  author  are  un- 
hesitatingly given  when  ditfering  from  the  gen- 
erally accepted  opinions ;  so  that  we  have  some- 
thing more  than  a  compilation  of  previously  de- 
scribed surgical  operations.  .  .  .  An  extended 
review  of  the  above  work,  while  desirable,  is  not 
allowable  from  the  limited  space  at  our  command. 
However,  we  can  assure  our  readers  that,  after  a 
careful  reading  of  Professor  Bryant's  book,  we  can 
unhesitatingly  recommend  it  for  information,  re- 
liability, and  guidance  on  all  connected  with  opera- 
tive surgery.  The  publishers'  part  of  the  work  is 
unusually  good,  and  the  numerous  illustrations  add 
much  to  its  value." — Folyclinic. 

"  The  book  is  one  which  we  feel  sure  will  recom- 
mend itself.  .  .  .  We  would  say  that  the  book 'met 
a  long-felt  want,'  if  we  dared  to  use  the  phrase. 


The  general  practitioner  who  occasionally  does  a 
little  surgery,  particularly  the  'dweller  in  the 
country  or  small  town,'  will  find  this  book  invalu- 
able, for  he  can  turn  in  a  minute  to  the  very  place 
he  wants,  and  find  there  an  intelligent  description 
of  instruments,  operation,  and  dressing." — Mary- 
land Medical  Journal, 

"  The  various  operative  procedures  are  clearly 
and  concisely  described,  and  the  results  of  the 
various  operations  briefly  stated.  .  .  .  The  work 
is  fully  abreast  of  the  most  recent  advances 
in  operative  surgery,  and  we  have  much  pleasure 
in  recommending  it  to  our  readers." — Canada 
Lancet. 

" .  .  .  In  concluding  our  notice  of  Professor 
Bryant's  book,  it  remains  for  us  to  congratulate 
him  upon  the  successful  result  of  his  labor.  He 
has  written  a  very  able  and  reliable  surgical  work, 
one  that  may  be  consulted  both  by  surgeon  ana 
student,  and  one  that  contains  all  the  more  im- 
portant advances  of  modern  surgery.  The  pub- 
lishers' part  of  the  work  has  been  well  done,  and 
the  numerous  illustrations  add  much  to  the  value 
of  the  volume." — Therapeutic  Gazette. 


BUCK.  Contributions  to  Reparative  Surgery,  showing  its  Applica- 
tiou  to  the  Treatment  of  Deformities,  produced  by  Destructive  Disease 
or  Injury  ;  Congenital  Defects  from  Arrest  or  Excess  of  Development  ; 
and  Cicatricial  Contractions  following  Burns.  Illustrated  by  Thirty  Cases 
and   fine   Engravings.      By   Gurdon    Buck,  M.  D.      8vo.      237   pages. 


Cloth,  $3.00. 


Specimens  or  Illustrations. 


"There  is  no  department  of  surgery  where  the  ingenuity  and  skill  of  the  surgeon  are  more  severely 
taxed  than  when  required  to  repair  the  damage  sustained  by  the  loss  of  parts,  or  to  remove  tlie  disfig- 
urement produced  by  destructive  disease  or  violence,  or  to  remedy  the  deformities  of  congenital  mal- 
formation. The  results  obtained  in  such  cases  within  the  last  half-century  are  among  the  most  satis- 
factory achievements  of  modern  surgery.  The  term  'Reparative  Surgery'  chosen  as  the  title  of  this 
volume,  thouffh  it  mav,  in  a  comprehensive  sense,  be  applied  to  the  treatment  of  a  great  variety  of 
lesions  to  which  the  bodv  is  liable,  is,  however,  restricted  in  this  work  exclusively  to  what  has  fallen 
under  the  autlior's  own  observation,  and  has  been  subjected  to  the  test  of  exjK'rience  in  his  own  practice. 
It  largely  embraces  the  treatment  of  lesions  of  the  face,  a  rcLtion  in  which  plastic  surgery  finds  its  most 
frequent  and  important  applications.  Another  and  no  less  important  class  of  lesions  will  also  be  found 
to  have  occupied  a  large  share  of  the  author's  attention,  viz.,  cicatricial  contractions  following  bums. 
While  these  cases  have  a  very  strong  claim  upon  our  commiseration,  and  should  stimulate  us,  as  sur- 
geons, to  the  greatest  efibrts  for  their  relief,  they  have  too  often  in  the  past  been  dismissed  as  hopelessly 
incurable.  The  satisfactory  results  obtained  in  the  cases  reported  in  this  volume  will  encourage  other 
surgeons,  we  trust,  to  resort  with  greater  hopefulness  in  the  future  to  operative  interfereuce.  _  Accuracy 
of  description  and  clearness  of  statement  have  been  aimed  at  in  the  following  patres;  and  if,  in  his  en- 
deavor to  attain  this  important  end,  the  author  has  incurred  the  reproach  ot  tediousness,  the  difficulty 
of  the  task  must  be  his  apology." — Extract  from  Preface. 


CATALOGUE  OF  MEDICAL   WORKS. 


9 


BURT.     Exploration  of  the  Chest  in  Health  and  Disease.     By 

SxEPHEisr  Smith  Burt,  M,  D.,  Professor  of  Clinical  Medicine  and  Physical 
Diagnosis  in  the  New  York  Post-Graduate  Medical  School  and  Hospital ; 
Physician  to  the  Out-Door  Department  (Diseases  of  the  Heart  and 
Lungs),  Bellevue  Hospital.  8vo,  210  pages.  With  Illustrations.  Cloth, 
11.50. 


"This  handy  little  book  has  lately  been  re- 
ceived by  us,  and  we  can  recommend  its  many 
virtues  and  its  usefulness  to  physicians  and  stu- 
dents. It  is  well  illustrated,  with  large,  clear  type, 
and  handsome  cloth  binding.  The  author's  object 
in  compounding  this  work  is  to  aid  the  student  in 
his  efforts  to  learn  the  significance  of  physical 
signs  and  their  mode  of  development.  He  has 
utilized  his  own  experience,  as  well  as  the  common 
stock  of  medical  teaching,  to  extend  to  others  the 
knowledge  of  the  relative  position  of  the  viscera  to 
the  parietes,  and  the  physical  signs  that  can  be  de- 
veloped in  the  normal  chest ;  for  upon  such  a  foun- 
dation rests  the  only  true  basis  for  a  correct  under- 
standing of  the  changes  caused  by  disease." — Texas 
Courier- Record  of  Medicine. 

"This  is  a  small  but  exceedingly  comprehen- 
sive book  on  auscultation  and  percussion,  and  is 
evidently  written  by  one  who  has  given  frequent 
instruction  on  the  subject.  .  .  .  After  each  disease 
a  summary  of  the  principal  signs  and  symptoms  is 
given.  The  book  is  well  printed,  with  a  sufficient 
number  of  cuts  and  diagrams  to  make  it  of  especial 
valae  to  students." — Maryland  Medical  Journal. 

"...  While  this  book  was  written  with  par- 
ticular reference  to  the  needs  of  the  student,  we 
are  sure  the  practitioner  will  find  it  immensely 


useful  for  his  needs  as  well.  Like  all  of  their 
books,  the  work  of  the  publishers  makes  it  a  model 
of  excellence." — Practice. 

"  The  aim  of  this  work  is,  as  described  by  the 
author,  to  emphasize  the  importance  of  knowing 
the  physiological  anatomy  of  the  heart  and  lungs, 
the  relative  position  of  the  viscera  to  the  parietes, 
and  the  physical  signs  that  can  be  developed  in  the 
normal  chest,  as  upon  such  a  foundation  rests  the 
only  true  basis  for  a  coiTect  understanding  of  the 
changes  caused  by  disease.  The  difficulty  encoun- 
tered in  producing  a  good  text-book  for  students 
has  been  ably  surmounted  in  this  instance.  _  Dr. 
Burt's  intimate  knowledge  of  his  subject,  utilized 
from  his  own  personal  experience  and  teaching, 
renders  this  a  work  at  once  sound  and  practical." — 
Medical  Brief. 

"  Dr.  Burt  has  not  attempted  to  establish  patho- 
gnomonic or  distinctive  signs  of  disease,  thinking 
that  precision  is  more  surely  attained  by  treating 
each  sign  as  subordinate  to  the  various  combina- 
tions of  signs  which  are  found  in  the  different 
maladies.  .  .  .  The  work  is  a  convenient  compila- 
tion of  knowledge  contained  in  various  text-books 
on  this  subject,  with  the  result  of  the  author's 
personal  experience  interspersed." — St.  Louis 
Medical  and  Surgical  Journal. 


CAMPBELL.  The  Language  of  Medicine.  A  Manual  giving  the 
Origin,  Etymology,  Pronunciation,  and  Meaning  of  the  Technical  Terms 
found  in  Medical  Literature.  By  F.  R.  Campbell,  A.  M.,  M.  D.,  Pro- 
fessor of  Materia  Medica  and  Therapeutics,  Medical  Department  of 
Niagara  University.     8vo,  325  pages.     Cloth,  13.00. 

"  We  welcome  with  much  gratification  a  volume 
which  forms  such  pleasant  rending  for  the  physi- 
cian who  may  desire  to  know  something  of  the 
grammar  and  orthography^  of  the  medical  portion 
of  the  English  language,  if  we  may  so  term_  it.  It 
is  a  sort  of  guide  or  introduction  to  the  dictionary, 
showing  him  why  the  words  exist,  or  rather  the 
foundation  of  their  existence.  The  mere  practi- 
tioner will  not  find  in  such  chapters  as  the  Origm 
of  Words,  The  Life  and  Death  of  Words,  Nomen- 
clature, etc.,  anything  available  for  him  in  the  next 
case  of  gastric  fever  or  diphtheria  he  may  be  called 
upon  to  attend,  but  Dr.  Campbell  has  given  much 
food  for  reflection  to  the  earnest,  thoughtful  student 
of  his  profession." — College  and  Clinical  Record. 

"  This  is  a  book  that  everybody  will  like. 
There  are  too  few  of  this  kind  written.  We  think 
it  is  just  the  sort  of  work  to  be  put  into  the  hands 
of  a  youth  previous  to  his  entry  into  a  medical 
school.  The  exorcises  are  excellent,  and  are  of 
more  use  than  the  ordinary  Latin  exercises  usually 
given  at  school,  for  they  bear  directly  on  future 
work.  There  is  too  little  preparatory  work  at 
schools  for  those  who  are  intended  for  a  special 
profession.  We  recommend  it  to  practitioners, 
especially  those  engaged  in  literary  work,  as  a  good 
book." — Pacific  Medical  and  Surgical  Journal  and 
Western  Lancet. 


"  A  most  valuable  book,  and  no  less  valuable 
than  charming.  Upon  studying  these  pages,  we 
begin  to  have  an  idea  of  the  manner  in  which  the 
names  of  our  various  diseases  originated.  .  .  . 
SuflBce  it  to  say  that  we  have  here  an  excellent  text- 
book and  history  combined,  a  work  which  will  be 
appreciated  by  both  old  and  young.  .  .  ." — Medi- 
cal Register. 

"...  Certainly  such  a  book  is  sadly  needed 
when  we  reflect  upon  the  wholesale  mispronuncia- 
tion, not  only  by  medical  students,  but  by  old  prac- 
titioners of  medicine.  To  the  medical  teacher,  stu- 
dent, and  practitioner,  Campbell's  'Language  of 
Medicine'  is  indispensable." — Practice. 

"  This  is  not  only  a  very  interesting  but  a  very 
instructive  book,  and  fulfills  the  object  intended  by 
the  author,  to  '  provide  the  medical  student  with  a 
suitable  means  of  acquiring  the  vocabulary  of  his 
science.'  Like  Shakespeare,  the  great  majority  of 
medical  students  have  but  '  small  Latin  and  less 
Greek.'  It  is  not  necessary  for  us  to  give  a  synop-i 
sis  of  the  work,  noi"  to  dwell  at  length  upon  any 
particular  part.  We  can  only  advise  our  readers 
to  procure  the  book  and  read  it  with  care.  We 
sincerely  believe  it  will  be  useful  to  old  and  young, 
and  especially  to  medical  students." — Columbus 
Medical  Journal. 


10 


D.  APPLETON  &    CO:S  ILLUSTRATED 


CARPENTER.  Principles  of  Mental  Physiology,  with  their  Ap- 
plications to  the  Training  and  Discipline  of  the  Mind  and  the  Study  of  its 
Morbid  Conditions.  By  AVilt.iam  B.  Carpenter,  M.  D.,  LL.  D.,  Regis- 
trar of  the  University  of  London,  etc.     8vo,  787  pages.     Cloth,  83.00. 

"  Among  the  numerous  eminent  writers  this  physiological  research  to  the  explanation  of  the 
country  has  produced,  none  are  more  deserving  of  mutual  relations  of  the  mind  and  body  than  Dr. 
praise  for  having  attempted  to  apply  the  results  of     Carpenter." — The  Lancet. 


CARTER.  Elements  of  Practical  Medicine.  By  Alfred  H,  Car- 
ter, M.  D.,  Member  of  the  Royal  College  of  Physicians,  London  ;  Phy- 
sician to  the  Queen's  Hospital,  Birmingham,  etc.  Third  edition,  revised 
and  enlarged.     12mo,  427  pages.     Cloth,  83.00. 

pages  are  occupied  with  the  diseases  of  the  circula- 
torj-  system.  If  the  reader  gets  the  impression  that 
the  physical  signs  are  given  somewhat  too  meager- 
ly,  it  is  to  be  said  tliat,  by  way  of  compensation, 
the  symptomatology  in  general  is  considered  with 
admirable  perspicuity  and  good  judgment." — JS'ew 
York  Medical  Journal. 


"  Although  this  work  does  not  profess  to  be  a 
complete  treatise  on  the  practice  of  medicme,  it  is 
too  full  to  be  called  a  compend ;  it  is  rather  an  in- 
troduction to  the  more  exhaustive  study  embodied 
in  the  larger  text-books.  An  idea  of  the  degree  to 
which  condensation  has  been  carried  in  it  can  be 
gathered  from  the  statement  that  but  twenty-one 


CASTRO.    Elements  of  Therapeutics  and  Practice  according  to 

the  Dosimetric  System.      By  Dr.  D'Oliveira  Castro.      8vo,  488 

pages.     Cloth,  84.00. 

"  This  translation  "  (of  Dr.  Castro's  work)  "  has  been  made  for  several  laymen  of  New  York  and 
Boston,  who,  having  derived  great  benefit  themselves  from  the  daily  use  of  the  alkaloids  as  recom- 
mended by  Dr.  Burggraeve,  are  desirous  of  bringing  this  admirable  book  to  the  knowledge  of  the 
physicians  of  the  United  States." — From  Preface  to  the  Ar/urica/i  Edition. 


CHAUVEAU.  The  Comparative  Anatomy  of  Domesticated 
Animals.  By  A.  Chauveau,  Professor  at  the  Lyons  Veterinary  School. 
Second  edition,  revised  and  enlarged,  with  the  co-operation  of  S.  Arloing, 
late  Principal  of  Anatomy  at  the  Lyons  Veterinary  School  ;  Professor  at 
the  Toulouse  Veterinary  School.  Translated  and  edited  by  George  Flem- 
ing, F.  R.  G.  S.,  M.  A.  I.,  Veterinary  Surgeon,  Royal  Engineers.  8vo,  957 
pages.     With  4ri0  Illustrations.     Cloth,  86.00. 


Specimen  of  iLLrsTKATioN. 


'•  Taking  it  altogether,  the  book  is  a  very  wel- 
come addition  to  EnwlLsh  literatm^e,  and  great  credit 
is  due  to  Mr.  Fleming  for  the  excellence  of  the  trans- 
lation, and  the  many  additional  notes  he  has  ap- 
pended to  Chauveau's  treatise." — Lancet  (^London). 

"The  descriptions  of  the  text  are  illustrated 


and  assisted  by  no  less  than  450  excellent  wood- 
cuts. In  a  work  which  ranges  over  so  vast  a  field 
of  anatomical  det,ail  and  description,  it  is  difficult 
to  select  any  one  portion  for  review,  but  our  ex- 
amination of  it  enables  us  to  speak  in  high  terms 
of  its  general  excellence.  .  .  . '' — Medical  Timet 
and  Gazette  {Londtjn). 


CATALOGUE   OF  MEDICAL   WORKS. 


11 


COMBE.  The  Management  of  Infancy,  Physiological  and  Moral. 
Intended  chiefly  for  the  Use  of  Parents.  By  A^jdeew  Combe,  M.  D. 
Revised  and  edited  by  Sir  James  Clark,  K.  C.  B.,  M.  D.,  F.  R.  S.,  Phy- 
sician-in-ordinary to  the  Queen.  First  American  from  the  tenth  London 
edition.     12mo,  303  pages.     Cloth,  $1.50. 

COOLEY'S  Cyclopaedia  of  Practical  Receipts.    See  Tuson,  page  50. 

CGRFIELD.  Health,  By  W,  H.  Coefield,  Professor  of  Hygiene  and 
Public  Health  at  University  College,  London.     12mo.    Cloth,  $1.25. 


"Few  persons  are  better  qualified  than  Dr. 
Cortield  to  write  intelligently  upon  the  j^ubject  of 
health,  and  it  is  not  a  matter  tor  surprise,  there- 
fore, that  he  has  given  us  a  volume  remarkable  for 
accuracy  and  interest.  Commencing  with  general 
anatomy,  the  bones  and  muscles  are  given  atten- 
tion ;  next,  the  cii'culation  of  the  blood,  then  res- 


piration, nutrition,  the  liver,  and  the  excretory 
organs,  the  nervous  system,  organs  of  the  senses, 
the  health  of  the  individual,  air,  foods  and  drinks, 
diinking-water,  climate,  houses  and  towns,  small- 
pox, and  communicable  diseases." — Philadelpfiia 
Item. 


CORNING.  A  Treatise  on  Brain  Exhaustion,  with  some  Preliminary 
Considerations  on  Cerebral  Dynamics.  By  J.  Leonard  Corning,  M.  D., 
formerly  Resident  Assistant  Physician  to  the  Hudson  River  State  Hospital 
for  the  Insane  ;  Member  of  the  Medical  Society  of  the  County  of  New 
York,  of  the  Physicians'  Mutual  Aid  Association,  of  the  New  York  Neu- 
rological Society,  of  the  New  York  Medico-Legal  Society,  of  the  Society 
of  Medical  Jurisprudence  ;  Physician  to  the  New  York  Neurological  In- 
firmary, etc.  ;  Member  of  the  New  York  Academy  of  Medicine.  Crown 
8vo.     Cloth,  $2.00. 

"  Dr.  Coming's  neat  little  volume  has  the  merit 
of  being  highly  siiggestive,  and,  besides,  it  is  better 
adapted  to'popular  reading  than  any  other  profes- 
sional work  on  the  subject  that  we  know  of." — Pa- 
cific Medical  and  Surgical  Journal. 

"This  is  a  capital  little  work  on  the  subject 
upon  which  it  treats,  and  the  author  has  presented, 
from  as  real  a  scientific  stand-point  as  possible,  a 
group  of  symptoms  the  importance  of  which  is 
sutficiently  evident.  To  fully  comprehend  the  ideas 
as  presented  by  the  author,  the  whole  book  should 
be  read  ;  and,  as  it  consists  of  only  234  pages,  the 
task  would  not  be  a  severe  or  tedious  one,  and  the 
information  or  knowledge  obtained  would  be  much 
more  than  equivalent  for  the  time  spent  and  cost  of 
book  included.  Literary  men  and  women  would 
d(J  well  to  procui'C  it." — Tlierapeutic  Gazette. 

"  This  book  belongs  to  a  class  that  is  more  and 
more  demanded  by  the  cultured  intelligence  of 
the  period  in  which  we  live.  Dr.  Corning  may 
be  ranked  with  Hammond,  Beard,  Mitchell,  and 
Crothers,  of  this  country,  and  with  Winslow,  An- 
stie,  Thompson,  and  more  recent  authors  of  Great 
Britain,  in  discussing  the  problems  of  mental  dis- 
turbance, in  a  style  that  makes  it  not  only  profitable 
but  attractive  reading  for  the  student  of  psychology. 
The  author  has  divided  the  work  into  short  chap- 
ters, under  general  headings,  which  are  again 
subdivided  into  topics,  that  are  paragraphed  in  a 
concise  and  definite  form,  which  at  once  strikes  the 
careful  reader  as  characteristic  of  a  method  that  is 
terse,  concise,  and  readily  apprehended.  There 
are  twenty-eight  of  these  pithy  chapters,  which  no 
student  of  mental  diseases  can  fail  to  read  without 
'oss." — American  Psychological  Journal. 


"...  In  this  work  on  the  exhaustion  of  the 
brain  the  author  presents,  in  a  very  clear  and  in- 
telligent form,  the  various  causes  and  symptoms  of 
the  complaint,  and  points  out  the  principles  upon 
which  its  treatment  should  be  pursued.  .  .  .  The 
subject  of  the  book  is  indeed  worthy  of  careful 
consideration,  and  it  is  presented  by  the  author  in 
such  a  pleasant  and  attractive  style  that  the  reader 
will  find  himself  entertained  as  well  as  instructed." 
Medical  Record. 

"...  The  study  of  what  is  now  becoming  a 
most  interesting  subject  to  the  general  practitioner, 
as  well  as  to  the  neurologist,  viz. :  intellectual 
diseases,  has  created  a  demand  for  works  of  the 
kind  before  us,  and  that  Dr.  Coming's  memoir 
will  meet  with  the  reception  that  its  merits  de- 
serve,  we  have  not  a  doubt." — Nev)  Orleans  Medi- 
cal and  Surgical  Journal. 

"...  The  quantity  of  advice  is  abundant,  and 
every  separate  chapter  is  instructive.  A  student 
having  the  intention  to  become  a  practitioner  will 
find  a  rich  store  of  material,  and  the  general 
reader  will  discover  much  to  interest  him,  even  in- 
cluding certain  passages  concerning  education." — 
PMladelpTiia  Eve>iing  Bulletin. 

"  Dr.  Cornins:  has  given  to  the  public  and  to 
the  medical  profession  a  work  which  reports  very 
creditably  the  results  of  a  somewhat  extended 
study  of  his  subject." — Providence  Evening  Herald. 

'• .  .  .In  some  respects  Dr.  Coming's  book  is 
entirely  original ;  m  othei-s  it  is  a  clear  arrange- 
ment and  condensation  of  facts  previously  known. 
It  distinctly  supplies  a  want  because  it  is  the  first 
book  on  the  subject  adapted  to  popular  reading.' 
— Journal  of  Commerce. 


12  D.  APPLET  ON  &    CO:S  ILLUSTRATED 


CORNING.    Local  Anaesthesia  in  General  Medicine  and  Surgery. 

Being  the  Practical  Application  of  the  Author's  Recent  Discoveries  in 
Local  Anaesthesia.  l>y  J.  Leonard  Corning,  M.  D.,  author  of  "  Brain 
Exhaustion,"  "  Carotid  Compression,"  "  Brain  Rest,"  etc.  ;  Fellow  of  the 
New  York  Academy  of  Medicine,  Member  of  the  Medical  Society  of  the 
County  of  New  York,  of  the  New  York  Neurological  Society,  etc.  Small 
8vo,  103  pages.    With  14  Illustrations.     Cloth,  $1.25. 

"  The  work  Jias  in  it  much  that  is  instructive  ten,  with  little  useless  padding.     The  author  stops 

and  attractive,  and  is  quite  an  addition  to  a  field  of  when  he   has  said  what  he  wishes." — American 

literature  which  may  be  considered  novel.  .  .  ." —  Lancet. 
College  and  Clinical  Record. 

"  The  book  should  find  its  way  everywhere  on  its  .  "  To  Dr.  Corning  belongs  the  honor  of  discov- 

merils,  and  will  be  welcomed  bv"a  host  of  interested  enng  that  cocaine  anesthesia  may  be  almost  indefi- 

rem^^.''— Medical  Press  of  Western  ^eiv  York.  ^itery  prolonged  by  checking  the  circulation  in  the 

part  aUiPsthetized  by  means  of  an  tsmareh's  band- 

"  This  is  a  valuable  little  work  on  cocaine,  giv-  age,  and  any  one  desiring  full  details  should  send 

ing  the  author's  method  of  increasing  and  prolonff-  to  the  Appletons  for  this  neat  little  work." — Kan- 

ing  the  cocaine  anaesthesia.  .  .  .  Some  very  tormida-  sas  City  Medical  Index. 
ble  operations,  even  amputation  of  the  thigh,  have 

been  performed  by  this  inethod  and  with  but  very  u  ^  jg  ^f  interest  to  note  the  author's  statement 

little  pain     It  is  a  valuable  contribution  to  surgical  ^■^^^  ^^e  '  discovery  in  question  was  in  no  respect 

practice."— Peorw  Medical  Monthly.  ^^^  j.gg^]^  ^j-  ^  chance,  but  was,  on  the  contrary,  the 

"  The  book  merits  careful  consideration,  as  being  ^lirect  outgrowth  of  a  chaiji  of  deductive  reasoning.' 

an  interesting  and  practical  original  contribution  to  The  importance  of  this  discovery  needs  no  insisting 

savsGrv.''— Medical  Bulletin.  on;  and  no  surgeon  can  afford  to  be  m  ignorance 

of  its  details,  or  can  fail  to  be  scientifically  the 

"  The  work  is  worthy  the  careful  study  of  every  richer  for  the  possession  of  the  present  work." — • 

practical  surgeon  and  physician.     It  is  clearly  writ-  New  England  Medical  Gazette. 

DAVIS.  Conservative  Surgery,  as  exhibited  in  remedying  some  of  the 
Mechanical  Causes  that  operate  injuriously  both  in  Health  and  Disease. 
With  Illustrations.  By  Henry  G.  Davis,  M.  D.,  Member  of  the  American 
Medical  Association,  etc.     8vo,  315  pages.     Cloth,  13.00. 

The  author  has  enjoyed  rare  facilities  for  the  study  and  treatment  of  certain  classes  of  disease, 
and  the  records  here  presented  to  the  profession  are  tne  gradual  accumulation  of  over  thirty  years' 
investigation. 

"  Dr.  Davis,  bringing  as  he  does  to  his  specialty  deem  it  worthy  of  a  place  in  every  physician's  li- 

a  great  aptitude  for  the  solution  of  mechanical  prob-  brary.     The  style  is  unpretending,  but  trenchant, 

lems,  takes  a  high  rank  as  an  orthopEcdic  surgeon,  graphic,  and,  best  of  all,  quite  intelligible." — Medi- 

and  his  very  practical  contribution  to  the  literature  cal  Record. 
of  the  subject  is  both  valuable  and  opportune.     We 

DOTY.  A  Manual  of  Instruction  in  the  Principles  of  Prompt 
Aid  to  the  Injured.  Designed  for  INIilitary  and  Civil  LTse.  By  Al- 
VAH  H.  Doty,  M.  D.,  Major  and  Surgeon,  Ninth  Regiment,  N.  G.  S.  N,  Y. ; 
Attending  Surgeon  to  Bellevue  Hospital  Dispensary,  New  York.  16mo. 
224  pages.     With  96  Illustrations.     Cloth,  $1.25. 

This  book  is  intended  to  impart  the  knowledge  necessary  for  the  prompt  and  intelligent  care  of  per- 
sons suffering  from  haemorrhage,  fractures,  dislocations,  wounds,  contusions,  burns,  shock,  sprains, 
(loisoning,  the  effects  of  heat  or  cold,  apoplexy,  epilepsy,  those  rescued  from  the  water,  and  other  acci- 
dents which  are  liable  to  occur  at  any  time,  the  results  of  which  may  be  materially  influenced  by  the 
care  and  attention  which  the  sutferer  receives  at  the  outset. 

In  order  that  the  book  may  be  read  intelligently,  the  author  has  given,  in  a  clear  and  simple  manner, 
the  elementary  principles  of  anatomy  and  physiology,  including  the  anatomy  of  bones,  ligaments,  carti- 
lacres^  joints,  muscles,  synovial  membranes,  arteries  and  veins,  and  the  physiology  of  circulation,  res- 
piration, alimentation,  secretion,  excretion,  and  the  nervous  system,  both  subjects  being  profusely  illus- 
trated with  woodcuts  which  contribute  much  to  a  clear  understanding  of  the  text.  This  is  followed  by 
instructions  in  bandaginir  and  the  use  of  antiseptics  and  disinfectants  ;  alter  which  the  various  conditions 
in  which  one  may  be  placed  by  accident  are  treated  in  a  manner  calculated  to  enable  anv  person,  who 
has  mastered  the  contents  of  the  book,  to  render  intelligent  assistance  to  the  sutferer.  Illustrations  are 
numerous  and  simplify  the  methods  described.     For  the  Ambulance  Corps  connected  with  the  different 


CATALOGUE  OF  MEDICAL  WORKS.  13 

regiments  of  militia  of  the  various  States,  for  which,  and  for  the  classes  for  instruction,  the  book  is 
esjjecially  clesij:;ned,  it  will  be  of  inestimable  value.  The  methods  employed  in  the  United  States  Army 
for  the  transportation  of  wounded  men,  the  manner  in  which  swords,  bayonets,  and  guns  can  be  used 
as  splints  or  as  means  of  transportation,  are  fully  described  and  illustrated. 

The  book  is  of  a  size  convenient  for  the  pocket,  and  embraces  a  greater  range  of  subjects  than  is 
found  in  any  work  of  the  kind  heretofore  published;  and  its  completeness  and  simplicity  commend  it 
to  the  general  public  as  well  as  to  that  portion  which  forms  the  militia  of  the  States  ot  the  Union. 

DOWN.  Health  Primers.  Edited  by  J.  La^ngdon  Down,  M.  D.,  F.  R. 
C.  P.  ;  Henry  Power,  M.  B.,  F.  R.  C.  S.  ;  J.  Mortimer-Granville, 
M.  D.  ;  John  Tweedy,  F.  R.  C.  S.  In  square  16mo  volume.  Cloth,  40 
cents  each. 

Though  it  is  of  the  greatest  importance  that  books  upon  health  should  be  in  the  highest  degree 
trustworthy,  it  is  notorious  that  most  of  the  cheap  and  popular  kind  are  mere  crude  compilations  of  in- 
competent persons,  and  are  often  misleading  and  injurious.  Impressed  by  these  considerations,  several 
eminent  medical  and  scientific  men  of  London  have  combined  to  prepare  a  series  of  Health  Primers 
of  a  character  that  shall  be  entitled  to  the  fullest  confidence.  They  are  to  be  brief,  simple,  and  ele- 
mentary in  statement,  filled  with  substantial  and  useful  information  suitable  for  the  guidance  of  grown- 
up people.  Each  primer  will  be  written  by  a  gentleman  specially  competent  to  treat  his  subject,  while 
the  critical  supervision  of  the  books  is  in  tne  hands  of  a  committee  who  will  act  as  editors. 

As  these  little  books  are  produced  by  English  authors,  they  are  naturally  based  very  much  upon 
English  experience,  but  it  matters  little  whence  illustrations  upon  such  subjects  are  drawn,  because  the 
essential  conditions  of  avoiding  disease  and  preserving  health  are  to  a  great  degree  everywhere  the  same. 

Volumes  now  ready. 

I.  Exercise  and  TEAiNiNa.  V.  Personal  Appearance  in  Health  and  Dis- 

II.  Alcohol:    its  Use  and  Abuse.  ease. 

III.  Premature    Death  :    its    Promotion   and        VI.  Baths  and  Bathing. 

Prevention.  VII.  The  Skin  and  its  Troubles. 

IV.  The  House  and  its  Surroundings.  VIII.  The  Heart  and  its  Functions. 

IX.  The  Nervous  System. 

ELLIOT.  Obstetric  Clinic.  A  Practical  Contribution  to  the  Study  of 
Obstetrics,  and  the  Diseases  of  Women  and  Children.  By  George  T. 
Elliot,  M.  D.,  late  Professor  of  Obstetrics  and  Diseases  of  Women  and 
Children  in  the  Bellevue  Hospital  Medical  College  ;  Physician  to  Bellevue 
Hospital  and  to  the  New  York  Lying-in  Asylum,  etc.  8vo,  458  pages. 
Cloth,  14.50. 

This  work  Ls,  in  a  measure,  a  resume  of  separate  papers  previously  prepared  by  the  late  Dr.  Elliot ; 
and  contains,  besides,  a  record  of  nearly  two  hundred  important  and  difficult  cases  in  midwifery,  selected 
from  his  own  practice.  The  cases  thus  collected  represent  faithfully  the  difficulties,  anxieties,  and  dis- 
appointments inseparable  from  the  practice  of  obstetrics,  as  well  as  some  of  the  successes  for  which  the 
profession  are  entitled  to  hope  in  these  arduous  and  responsible  tasks.  It  has  met  with  a  hearty  recep- 
tion, and  has  received  the  highest  encomiums  both  in  this  country  and  in  Europe. 

EVANS.  Hand-Book  of  Historical  and  Geographical  Phthisi- 
ology,  with  Special  Refei'ence  to  the  Distribution  of  Consumption  in  the 
United  States.  Compiled  and  arranged  by  George  A.  Evans,  M.  D., 
Member  of  the  Medical  Society  of  the  County  of  Kings,  New  York  ; 
Member  of  the  American  Medical  Association  ;  formerly  Physician  to  the 
Atlantic  Avenue,  and  Bush  wick  and  East  Brooklyn  Dispensaries,  etc. 
8vo,  294  pages.     Cloth,  ^2.00. 

"  This  work  of  Dr.  Evans's  presents  a  most  The  author  has  evidently  exercised  an  unusual 

•comprehensive  view  of  the  subject  of  phthisis,  amount  of  painstaking  care  in  the  compilation  of 

The  historical  sketch  of  the  disease  is  complete  and  his  statistics,  with  the' result  of  affording  the  reader 

entertaining,  the  account  of  the  geographical  dis-  an  accurate  picture  of  the  climatic  and  geographical 

tribution,  both  in  this  country  and  abroad,  very  factors  that  bear  such  an  important  part  in  the  dis- 

instructive,  and  the  conclusions  drawn  are  logical  tribution  of  the  disease.     The  book  is  one  which 

and  concise.     Considerable  space  is   given  to  the  should  meet  with  a  large  sale." — Pittsburgh  Medi- 

topography  and  meteorology  of  different  parts  of  cal  Review. 
the  United  States  with  reference  to  consumption. 


14 


D.  APPLETON  &    CO:S  ILLUSTRATED 


"...  A  work  in  which  is  collected  all  the 
known  facts  in  reijard  to  the  disease  must  certainly 
excite  such  interest  as  to  cause  every  physician  to 
desire  to  have  a  copy  of  it  in  his  library." — Cin- 
cinnati Medical  News. 

"  Dr.  Evans  has,  in  this  little  volume,  rendered 
an  immense  assistance  to  the  practitioner  in  the 
way  of  detennininir  tor  him  the  best  locality  for 
patients  suifering  with  a  disease  with  which  climate 
and  location  have  more  to  dt)  than  any  other  malady 
to  which  the  human  flesh  is  heir.  .  .  .  We  com- 
mend it  to  our  readers  as  a  valuable  addition  to 
their  libraries." — American  Medical  Digest. 

"...  It  i)resents  the  most  reliable  data  obtain- 
able, and  is  altogether  an  interesting  and  valuable 
book." — 2^ew  England  Medical  Monthly. 


"...  It  has  a  peculiar  value  of  its  own  in 
bringing  into  practical  relationships  facts  more  or 
less  isohited  and  dithcult  of  access." — American 
Lancet. 

"  In  compiling  the  above  work.  Dr.  Evans  has 
rendered  a  most"  useful  service  to  the  profession. 
Heretofore  it  has  been  necessary  to  glean  from 
many  so\irces  the  knowledge  here  contained  in 
one  small  volume.  Any  one  who  has  had  occasion 
to  perform  this  arduous  work  will  appreciate  at 
once  the  labors  of  the  author.  .  .  .  The  task  has 
been  performed  thoroughly  and  well.  ...  We 
feel  sure  the  book  will  be  found  upon  the  table  of 
every  physician  interested  in  this  widespread  and 
fatafdisease.  .  .  ." — Buffalo  Medical  and  iSui'gical 
Journal. 


EVETZKY.  The  Physiological  and  Therapeutical  Action  of 
Ergot.  Being  the  Joseph  Mather  Smith  Prize  Essay  for  1881.  \iy 
Etienxe  Evetzky,  M.  D.     8vo.     Limp  cloth,  $1.00. 

"In  undertaking  the  present  work  my  object  was  to  present  in  a  condensed  manner  all  the  thera- 
peutic possibilities  of  ergot.  In  a  task  of  this  nature,  original  research  is  out  of  the  question.  No> 
man's  evidence  is  sufficient  to  establish  the  merits  of  a  drug  considered  in  the  manner  indicated,  and 
no  one  man's  opportunities  are  sufficient  to  grasp  the  entire  subject.  Consequently  it  remained  to  gather 
from  the  volumes  of  pa-st  and  current  periodical  literature  the  testimony  of  the  multitude  of  physicians 
that  had  been  led  to  use  ergot  in  difterent  morbid  conditions.  I  have  recorded  everything  that  has- 
come  to  my  notice,  I  have  grouped  and  classified  the  immense  material  in  our  possession.  In  all  cases- 
in  which  the  action  of  ergot  could  be  explained  I  have  attempted  to  do  so,  altiiough  this  task  is  fre- 
quently difficult,  if  not  impossible.  .  .  .  The  reader  will  see  that  ergot  has  been  used  in  a  large  number 
of  diseases;  some  of  these  uses  have  little  or  no  practical  value,  yet" it  is  very  important  to  know  them, 
a.s  they  serve  to  illustrate  the  therapeutic  properties  of  the  drug.  "  They  have  been  brought  to  the  notice 
of  the'  reader  witliout  any  comments,  but  those  that  are  essential  and  of  the  greatest  practical  impor- 
tance have  been  dealt  with  more  fully.  Among  the  latter  may  be  mentioned  the  use  of  ergot  in  inflam- 
mation, aneurism,  cardiac  diseases,  tlie  post-parturient  state,  uterine  fibroid  tumors,  rheumatism,  etc." 
— From  Preface. 


FLINT.  Text-Book  of  Human  Physiology,  for  the  Use  of  Students 
and  Practitioners  of  Medicine.  B}^  Austin  Flint,  M.  D.,  LL.  D.,  Profes- 
sor of  Physiology  and  Physiological  Anatomy  in  the  Eellevue  Hospital 
Medical  College,  New  York  ;  Fellow  of  the  New  York  State  Medical  As- 
sociation, etc.  Fourth  edition.  Entirely  rewritten.  In  one  large  8vo 
volume  of  872  pages,  elegantly  printed  on  fine  paper,  and  profusely  illus- 
trated with  two  Lithographic  Plates  and  316  Engravings  on  Wood.    Cloth,, 

86.00  ;  sheep,  17.00. 


Specimen  of  iLLrsxRATiON. 


"Flint's  Physiology  needs  no  introduction  to- 
the  profession,  as  it  has  been  a  standard  text-book 
since  its  first  appearance  in  1875.  In  this  edition 
the  text  has  been  entirely  rewritten,  and  all  the 
new  facts  that  have  been  established  are  intro- 
duced, so  that  it  is  essentially  a  new-  treatise,  the- 
changed  form  and  typography  of  the  book  also- 
giving  it  the  countenance  of  a  stranger,  until  we 
trace  in  the  general  plan  and  arrangement  the  old, 
familiar  lineaments  of  its  predecessors.  Obsolete 
matter,  peculiar  views  and  theories,  historical 
references,  lengthy  descriptions  of  experimental 
methods  and  apparatus  have  all  been  wisely 
omitted.  So  also  of  minute  anatomy,  which  has- 
only  becii  considered  incidentally,  and  consigned 
to  its  proper  )ilace  in  works  on  anatomy. 

"The  object  being  to  make  a  text-book  of 
{physiology,  only  recognized  and  well-established 
tacts  have  necn  presented  ;  but  no  pains  have  been 
spared  to  present  these  in  such  a  clear  and  con- 
nected manner  as  to  give  the  student  the  plainest 
sailing  possible.  With  this  end  in  view,  great  im- 
provements have  been  made  in  the  illastrations. 


CATALOQTJE   OF  MEDICAL   WORKS. 


15 


"It  is  a  complete  and  reliable  text-book,  up  to 

the  times,  and  written  by  one.  who  has  definite  ideas 
of  what  a  text-book  should  and  should  not  contaiia. 
Besides,  we  are  proud  of  it  as  an  American  pro- 
duction, and  hope  to  see  it  still  more  extensively 
used  in  American  colleges." — Cleveland  Medical 
Gazette. 

"  This  is  the  fourth  edition  of  one  of  the  most 
popular  American  text-books.  A  comparison  with 
former  editions  shows  that  while  the  creneral  ai-- 
rangement  of  subjects  has  been  retained,  but  little 
remains  of  the  original  text ;   it  has,  indeed,  been 

"  To  those  familiar  with 
the  merits  of  Prof.  Flint's 
physiology,  it  is  only  neces- 
sary to  say  that  the  present 
volume  retains  all  the  ex- 
cellences of  its  predecessors, 
and  will  be  found  a  reliable 
and  useful  work  of  reference 
for  the  practitioner  who  de- 
sires to  inform  himself  as  to 
the  present  state  of  physio- 
logical science.  To  the  medi- 
cal student  this  work  will 
commend  itself  on  account 
of  its  clearness,  conciseness, 
and  intelligible  presentation 
of  the  fundamental  and 
generally  accepted  facts  of 
physiology.  The  author  has 
selected,  with  judicious  care 
and  excellent  judgment, 
those  physiological  facts  and 
theories  which,  when  once 
comprehended,  will  materi- 
ally assist  the  student  in  the 
elucidation  of  clinical  and 
pathological  problems,  and 
will  thus  serve  to  reveal  the 
close  relationship  and  inter- 
dependence of  physiology 
and  general  medicine." — 
Pohjciinic. 

"  The  great  charm  of 
Flint's  work  on  physiology 
is  that  it  is  made  interesting 
to  the  reader.  This  does  not 
by  any  means  imply  that  it 
is  a  popular  work,  or  one 
addressed  to  tiie  unprofes- 
sional mind,  for  it  is  as  thor- 
oughly scientific  and  goes  as 
fully  into  all  technical  de- 
tails as  it  could  if  written  in 
the  dryest  and  most  prosaic 

style.  But  the  author  has  a  knack  of  weaving  to- 
gether his  facts  into  so  connected  a  form  that  many 
parts  of  the  book  are  absorbing  in  their  interest. 
Many  works  on  physiology,  notably  those  of  the 
Germans,  consist  of  a  mere  record  of  the  results  of 


entirely  rewritten  in  order  to  keep  pace  with  the 
rapid  advances  in  physiological  research.  The 
author  has  adopted  the  new  chemical  nomenclature, 
and  he  has  very  wisely  retained  the  English 
weights  and  measures  and  the  Fahrenheit  scale  of 
the  thermometer,  placing  their  metric  equivalents 
in  parentheses. 

"  If  one  thing  more  than  another  has  contributed 
to  make  this  tlie  text-book  of  human  physiology, 
it  is  that  established  facts  have  been  allowed  to  take 
precedence  over  peculiar  views  and  pet  theories, 
whether  of  the  author  or  of  others.'' — Practice. 

Specimen  of  Illustration. 


operations  and  experiments,  the  facts  grouped  ac- 
cording to  the  part  or  organ  described,  but  their 
relation  to  one  another  and  the  outcome  of  the 
whole  often  left  for  the  student  to  figure  out  for 
himself. ' '  — Sorthioestern  Lancet. 


FLINT.  Manual  of  Chemical  Examination  of  the  Urine  in 
Disease.  With  Brief  Directions  for  the  Examination  of  the  most  Com- 
mon Varieties  of  Urinary  Calculi.  By  AusTii^f  Flixt,  M.  D.,  LL.  D.,  Pro- 
fessor of  Physiology  and  Microscopy  in  the  Bellevue  Hospital  Medical 
College  ;  Fellow  of  the  New  York  Academy  of  Medicine,  etc.  Fifth 
edition,  revised  and  corrected.     12mo.     77  pages.     Cloth,  SI. 00. 

The  chief  aim  of  this  little  work  is  to  enable  the  busy  practitioner  to  make  for  himself,  rapidly  and 
easily,  all  ordinary  examinations  of  Urine  ;  to  give  him'the  benefit  of  the  author's  experience  in  elimi- 
nating little  difficulties  in  the  manipulations,  and  in  reducing  processes  of  analysis  to  the  utmost 
simplicity  that  is  consistent  with  accuracy. 


16  D.  APPLETON  &    CO:S  ILLUSTRATED 

FLINT.  Medical  Ethics  and  Etiquette.  Commentaries  on  the 
National  Code  of  Ethics.  By  Austin  Flint,  M.  D.,  LL.  D.  12mo.  101 
pages,     60  cents. 

ELiINT.  Medicine  of  the  Future.  An  Address  jirepared  for  the  An- 
nual Meeting  of  the  British  Medical  Association  in  1886.  By  Austin 
Flint  (Senior),  M.  D.,  LL.  D.  With  Steel  Engraving  of  the  author, 
12mo.     37  pages.     Cloth,  $1,00, 

"  The  late  Dr.  Austin  Flint  was  appointed  to  "  The  above,  the  last  of  tlie  tlioughts  of  Austin 
read  the  address  on  Medicine  before  the  British  Flint,  should  be  in  the  hands  of  every  admirer  of 
Medical  Association  at  its  meetinii:  in  1886.  The  the  great  and  good  physician,  and  who  that  knows 
manuscript  was  found  among  liis  papers,  and  the  anything  of  American  medicine  did  not  admire 
address  is  printed  precisely  as  It  was  written.  The  him?  Flint  never  wrote  anything  that  was  not 
proof  was  reverently  read  by  his  son,  who  dedicates  good,  and  the  nice  little  book — souvenir — before  us 
this,  his  father's  last  literary  work,  to  the  pro-  bears  that  characteristic.  The  manuscript  was 
fession  he  so  loved  and  admfred.  The  book  con-  found  among  his  papers  after  his  death,  and  was 
tains  an  excellent  portrait  of  the  late  Dr.  Flint.  It  printed  just  as  it  was  written.  It  contains  a  good 
is  a  most  fitting  memorial  volume.  The  address  likeness  of  the  author — an  elegant  steel  engraving 
itself  is  a  most  scholarly  work,  and  should  be  — and  nothing  has  been  left  undone  by  the  well- 
added  to  the  library  of  every  practitioner." — Buf-  known  publishers  to  make  it  attractive." — Missis- 
falo  Medical  and  Surgical  Journal.                      '  sippi  Valley  Medical  Monthly. 

FLINT.  On  the  Physiological  Effects  of  Severe  and  Protracted 
Muscular  Exercise.  With  special  reference  to  its  Influence  upon  the 
Excretion  of  Nitrogen.  By  Austin  Flint,  M,  D.,  LL.  D.,  Professor  of 
Physiology  in  the  Bellevue  Hospital  Medical  College,  New  York,  etc,  etc. 
8vo,     91  pages.     Cloth,  $1,00. 

This  monograph  on  the  relations  of  Urea  to  Exercise  is  the  result  of  a  thorough  and  careful  investi- 
gation made  in  the  case  of  Mr.  Edward  Payson  Weston,  the  celebrated  pedestrian.  The  chemical 
analyses  were  made  under  the  direction  of  R. 'O.  Doremus,  M.  D.,  Professor  of  Chemistry  and  Toxicol- 
ogy in  the  Bellevue  Hospital  Medical  College,  by  Mr.  Oscar  Loew,  his  assistant.  The  observations 
were  made  with  tlie  co-operation  of  J.  C.  t)alton,  M.  D.,  Professor  of  Physiology  in  the  College  of 
Physicians  and  Surgeons;  Alexander  B.  Mott,  M.  D.,  Professor  of  Surgical  Anatomy;  W.  H.Van 
Buren,  M.  D.,  Professor  of  Principles  of  Surgery  ;  Austin  Flint,  M.  D.,  Professor  of  the  Principles  and 
Practice  of  Medicine;  W.  A.  Hammond.  M.  D.,  Professor  of  the  Diseases  of  the  Mind  and  Nervous 
System — all  of  the  Bellevue  Hospital  Medical  College. 

ELINT.  The  Source  of  Muscular  Power.  Arguments  and  Conclu- 
sions drawn  from  Observations  upon  the  Human  Subject  under  conditions 
of  Rest  and  of  Muscular  Exercise,      By  Austin  Flint,  M,  D,,  LL.  D,, 

Professor  of  Physiology  in  the  Bellevue  Hospital  Medical  College,  New 
York,  etc,  etc,     8vo.     103  pages.     Cloth,  $1,00, 

"  There  are  few  questions  relating  to  Philosophy  of  greater  interest  and  importance  than  the  one 
which  is  the  subject  of  this  essay.  I  have  attempted  to  present  an  accurate  statement  of  my  own  obser- 
vations and  what  seem  to  me  to  be  the  logical  conclusions  to  be  drawn  from  them,  as  well  as  from 
experiments  made  by  others  upon  the  human  subject  under  conditions  of  rest  and  of  muscular 
exercise." — From  the  Pi'eface. 

FOSTER.  The  First  and  Second  Volumes  of  an  Illustrated  En- 
cyclopeedic  Medical  Dictionary.  Being  a  Dictionary  of  the  Tech- 
nical Terms  used  by  writers  on  Medicine  and  the  Collateral  Sciences  in 
the  Latin,  English,  French,  and  German  Languages.  By  Frank  P,  Fos- 
ter, M,  D,,  Editor  of  "The  New  York  Medical  Journal,"  With  the 
Collaboration  of  W,  C.  Ayres,  M,  D,  ;  E,  B.  Bronson,  M,  D,  ;  C,  S, 
Bull,  M,  D,  ;  H,  C.  Coe,  M.  D.,  M.  R,  C.  S,,  etc,  ;  A.  F,  Currier,  M.  D.  ; 
A.  DuANE,  M,  D.  ;  Prof,  S.  H,  Gage  ;  H.  J.  Garrigues,  M.  D.  ;  C.  B, 
Kelsey,  M,  D.  ;  R.  H,  Nevins,  M,  D.  ;  and  B.  G.  Wilder,  M.  D.  This 
work  will  be  completed  in  Four  Volumes,  and  is  sold  by  Subscription  only. 


CATALOGUE  OF  MEDICAL   WORKS. 


lY 


Specimen  of  Illcstkation. 

20   12    i-j 

22 


THE    GALL-BLADDER   AND   ADJACENT    STRUCTURES.         (FROM    FLINT,    AFTER    SAPPEY.) 

1,2, 3,  duodenum;  4,4,5,  6.  T,  7,  8,  pancreas  and  pancreatic  ducts;  9,10,  11, 12, 13,  liver;  14,  g-all-bladder ;  15,  hepatic 
dutt;  16,  cystic  duct;  IT,  common  duct;  IS,  portal  vein;  19,  branch  from  the  cceliac  axis;  20,  hepatic  artery;  21, 
coronary  artery  of  the  stomach ;  22,  cardiac  portion  of  the  stomach ;  23,  splenic  artery ;  24,  spleen ;  25,  left  kidney  ; 
26,  right  kidney  ;  27,  superior  mesenteric  artery  and  vein ;  23,  inferior  vena  cava. 

The  distinctive  features  of  Foster's  "Illustrated  Encyclopfedie  Medical  Dictionary"  are  as  follows: 

It  is  founded  on  independent  reading,  and  is  not  a  mere  compilation  from  other  medical  dictionaries, 
consequently  its  definitions  are  more  accurate.  Other  medical  dictionaries  have,  it  is  true,  been  con- 
sulted constantly  in  its  preparation,  but  what  has  been  found  in  them  has  not  been  accepted  unless 
scrutiny  showed  it  to  be  correct. 

It  states  the  sources  of  its  information,  thus  enabling  the  critical  reader  to  provide  himself  with 
evidence  by  winch  to  judge  of  its  accuracy,  and  also  in  many  instances  guiding  him  in  any  further  study 
of  the  subject  that  he  may  wish  to  make. 

It  is  the  only  work  of  the  kind  printed  in  the  English  language  in  which  pictorial  illustrations  are  used. 

It  tells,  in  regard  to  every  word,  what  part  of  speech  it  is,  and  does  not  define  nouns  as  if  they  weie 
adjectives,  and  vice  versa ;  and  it  does  not  give  French  adjectives  as  the  "analogues"  of  English  or 
Latin  nouns. 

It  contains  more  English  and  Latin  major  headings  than  any  other  medical  dictionary  printed  in 
English  or  Latin,  more  French  ones  than  any  printed  in  French,  and  more  German  ones  than  any 
printed  in  German,  all  arranged  in  a  continuous  vocabulary. 

The  sub-headings  are  usually  arranged  under  the  fundamental  word,  making  it  much  more  encyclo- 
paedic in  character  than  if  the  common  custom  had  been  followed. 


FOTHERGILL.  The  Diseases  of  Sedentary  and  Advanced  Life. 
A  Work  fob  Medical  and  Lay  Readers.  By  J.  Milister  Fothergill, 
M.  D.,  M.  R.  C.  P.,  Physician  to  the  City  of  London  Hospital  for  Diseases 
of  the  Chest  (Victoria  Park)  ;  late  Assistant  Physician  to  the  West  Lon- 
don Hospital ;  Hon.  M.  D.,  Rush  Medical  College,  Chicago  ;  Foreign  As- 
sociate Fellow  of  the  Royal  College  of  Physicians  of  Philadelphia,  Small 
8vo.     296  pages.     Cloth,  $2.00. 


"  The  book  is  full  of  useful  and  wise  hints  for 
the  physician  and  lay  reader,  whether  an  adult  or 
already  of  advanced  years,  who  may,  by  digesting 
the  instruction  he  finds  within  its  covers,  very  ma- 
terially lengthen  his  life." — Pacific  Medical  and 
Surgical  Journal  and  Western  Lancet. 

"  It  is  difficult  to  select  from  a  book  of  such  all- 
round  goodness  any  special  points  for  notice.  It 
must  sutiice  to  say  that  it  is  such  a  work  as  the 
physician  may  not  only  read  himself  but  especially 

2 


recommend  to  such  of  his  more  intelligent  patrons 
as  are  passing  into  the  sere  and  yellow  leaf." — 
Medical  Age. 

"  The  present  woi-k  is  really  a  valuable  one. 
It  covers  a  ground  which  is  usually  but  lightly 
touched  upon  by  the  ordinary  text-book.  It  is  full 
of  vahiable  suifgestions,  and  either  the  old  or  young 
physician  who  may  take  it  up  will  read  it  through 
with  interest  and  profit." — Buffalo  Medical  and 
Surgical  Journal. 


18  D.  APPLETON  &   CO:S  ILLUSTRATED 

FOURNIER.  Syphilis  and  Marriage.  Lectures  delivered  at  the  St. 
Louis  Hospital,  Paris.  By  Alfred  Fournier,  Professeur  k  la  Faculte  de 
Medecine  de  Paris  ;  Medecin  de  I'Hopital  Saint-Louis.  Translated  by  P. 
Albert  Morrow,  M.  D.,  Physician  to  the  Skin  and  Venereal  Department, 
New  York  Dispensary,  etc.,  etc.     8vo.     Cloth,  $2.00  ;  sheep,  $3.00. 

"  The  hook  supplies  a  want  loug  recognized  in  "  Written  with  a  perfect  fairness,  with  a  supe- 

raedical  literature,  and  is  based  upon  a  very  ex-  rior  ability,  and  in  a  style  v.hich,  without  aiming  at 

tended  experience  in  the  special  hospitals  for  syph-  effect,  engages,  interests,  persuades,  this  work  is 

ilis  of  Paris,  which  have  furnished  the  author  with  one  of  those  which  ought  to  be  immediately  placed 

a  rich  and  rare  store  of  clinical  cases,  utilized  by  in  the  hands  of  every  physician  who  desires  not 

him   with    great  discrimination,   oriijinality,  and  only  to  cure  his  patients,  but  to  understand  and  ful- 

clinieal  judgment.  It  exhibits  a  profound  knowl-  fill  his  duty  as  an  honest  man." — Lyon  Medicale. 
edge  of  its  subject  under  all  relations   united  with 

marked  skill  and  tact  in  treating  the  delicate  social  u  j^o  physician,  who  pretends  to  keep  himself 

questions  necessarily  involved  m  such  a  line  ot  in-  informed  upon  the  grave  social  questions  to  which 

vestigation.     The  entire  volume  is  full  ot    intor-  x,h\s  disease  imparts  an  absorbing  interest,  can  af- 

mation,  mnemonically   condensed   into  axiomatic  ford  to   leave  this   valuable  work   unread."— ^'i!. 

'points.'     It  is  a  book  to  buy,  to  keep,  to  read,  to  Xo«««  Clinical  Becc/rd. 
profit  by,  and  to  lend  to  others." — Boston  Medical 

and  Surgical  Journal.  ,,  ^j^^  ^^^^^^  ^^^^^^^  ^j^j^  ^^.^^,^  ^^^i^j  p^^^j^^ 

,,  ™,  .            ,       ,.   ^,         ,,          1     1-  .•        •  I,    1  without  stint.     A   general   perusal  of  this   work 
"This  work    o     the  able  and    distinguished  would  be  of  untold  benefit  to  society.  "-Zo«m'i7^e 
French  syphilogranher,  Professor  P  ournier  is  with-  j^^^^^^i  ^^^^.^^ 
out  doubt  one  ot  the  most  remarkable  and  impor- 
tant productions  of  the  dav.     Possessing  profound  ,,  _,                    ./.,,,.    i                         .     i        ■ 
knowledge  of  syphilis  in  all  its  protean  forms,  an  ,       Everj  page  is  lull  ot  the  most  practical  and 
unexcelled  e.xnenence,  a  dramatic  force  of  expres-  P^am  advice,  couched  in  vigorous,  emphatic  lan- 
eion,  untinsjea,  however,  by  even  a  suspicion  of  »uage.       Detroit  Lancet. 
exaggeration,  and  a  rare  tact  in  dealing  with  the 

most  delicate  problems,  he  has  given  to  the  world  "  The  subject  here  presented  is  one  of  the  most 
a  series  of  lectures  which,  by  their  fascination  of  important  that  can  engage  the  attention  of  the  pro- 
style, compels  attention,  and  by  their  profundity  fession.  The  volume  should  be  generally  read,  as 
of  wisdom  carries  conviction." — St.  Louis  Courier  the  subject-matter  is  of  great  importance  to  so- 
of  Medicine  and  Collateral  Sciences.  ciety." — Maryland  Medical  Journal. 

FREY.  The  Histology  and  Histo-Chemistry  of  Man.  A  Prac- 
tical Treatise  on  the  Elements  of  Composition  and  Structure  of  the  Hu- 
man Body.  By  Heinrich  Frey,  Professor  o£  Medicine  in  Zurich.  Trans- 
lated from  the  fourth  German  edition,  by  Arthur  E.  J.  Barker,  Surgeon  to 
the  City  of  Dublin  Hospital  ;  Demonstrator  of  Anatomy,  Royal  College 
of  Surgeons,  Ireland  ;  and  revised  by  the  Author.  With  680  Engravings. 
8vo.     683  pages.     Cloth,  $5.00  ;  sheep,  16.00. 

CONTENTS.— ThQ  Elements  of  Composition  and  of  Structure  of  the  Body  :  Elements  of  Compo- 
sition— Albuminous  or  Protein  Compounds,  Hasmoglobulin,  Histogenic  Derivatives  of  the  Albuminous 
Substances  or  Albuminoids,  the  Fatty  Acids  and  Fats,  the  Carbo-hydrates,  Non-Nitrogenous  Acids, 
Nitrogenous  Acids,  Amides,  Amido- Acids,  and  Organic  Bases,  Animal  Coloring  Matters,  Cyanogen 
Compounds,  Mineral  (Constituents ;  Elements  of  Structure — the  Cell,  the  Origin  of  the  Eemaimng  Ele- 
ments of  Tissue ;  the  Tissues  of  the  Body— Tissues  composed  of  Simple  Cells,  with  Fluid  Intermediate 
Substance,  Tissues  composed  of  Simple  Cells,  with  a  small  amount  of  Solid  Intermediate  Substance, 
Tissues  belonging  to  the  Connective  Substance  Group,  Tissues  composed  of  Transformed  and,  as  a  rule. 
Cohering  Cells,  with  Homogeneous,  Scanty,  and  more  or  less  Solid  Intermediate  Substance  ;  Composite 
Tissues :  The  Organs  of  the  Body — Organs  of  the  Vegetative  Type,  Organs  of  the  Animal  Group. 

FRIEDLAENDER.  The  Use  of  the  Microscope  in  Clinical  and 
Pathological  Examinations.  By  Dr.  Carl  Friedlaexder,  Privat- 
Docent  in  Pathological  Anatomy  in  Berlin.  Translated  from  the  enlarged 
and  improved  second  edition,  by  Henry  C.'Coe,  jM.  D.,  etc.  With  a  Chro- 
mo-Lithograph.     12mo.     195  pages.     With  copious  Index.     Cloth,  11.00. 

"  We  are  very  much  pleased  to  see  Dr.  Fried-  book  in  his   po.ssession.  .  .  .  The   translator   has 

laender's  little  book  make  its  appearance  in  English  done  his  work  well,  and  has  certainly  conferred  a 

dress.     As  we  have  a  practical  acquaintance  of  the  great  favor  on  all  microscopists  by  placing  within 

German  edition  since  its  appearance,  we  can  speak  the  reach  of  everv  one  the  work  of'so  accomplished 

of  it  in  terms  of  unqualified  nraise.  .  .  .  Everyone  a  teacher    as   Dr.    Carl    Friedlaender."— Cawa^^a 

doing  pathological   work  should  have  this  little  Medical  and  Surgical  Journal. 


CATALOGUE  OF  MEDICAL  WORKS. 


19 


"  Much  ^ood  has  been  done  in  placing  this  little 
work  in  thenands  of  the  profession.  The  technique 
of  preparina-,  cutting,  and  staining  specimens  is 
given  at  some  length  ;  also  rules  for  the  examina- 
tion of  the  various  bodily  fluids  in  both  health  and 
disease.  The  use  of  the  microscope  with  high  pow- 
ers, immersion  lenses,  and  other  accessories,  is  ex- 
plained very  clearly.  It  is  a  very  readable  volume, 
even  for  those  not  engaged  in  actual  laboratory 
work.  A  chromo-lithograph  shows  the  various 
forms  of  disease-germs  which  have  been  definitely 
isolated." — Medical  Record. 

"  Microscopical  teeTiuique  has  unproved  so  much 
of  late,  especially  in  the  direction  of  studying 
parasites,  that  amateurs  must  keep  constantly  on 
the  lookout  for  all  that  is  new,  or  they  wdll  find 
their  work  of  little  avail.  The  book  before  us  is 
designed  for  just  such  workers ;  it  is  small,  simple, 
compact,  but  contains  all  that  one  needs  to  know." 
— Columbus  Medical  -Journal. 

"  This  is  one  of  the  best  books  of  the  kind. 
Its  descriptions  are  short,  detailed,  and  accurate. 
It  is  devoted  wholly  to  descriptions  of  the  methods 
best  adapted  to  use  for  makmg  microscopical  ex- 
aminations for  clinical  purposes.     By  those  inter- 


ested in  this  subject,  and  especially  by  the  begin- 
ner, "will  this  little  book  be  found  valuable^" — 
Journal  of  the  American  Medical  Association. 

"  This  is  the  very  book  on  microscopy  that  the 
general  run  of  practitioners  have  long  been  want- 
ing. Many  doctors  recognize  their  ignorance  on 
the  subject  who,  "whUe  neither  expecting  nor  caring 
to  become  expert  microscopists,  do  want  to  know, 
in  plain  language  that  is  easily  intellio-ible,  how 
normal  structures  and  abnomial  tissues  Took  under 
the  microscope.  This  book  is  a  great  help  to  such 
a  practitioner,  and  will  do  much  to  popularize  the 
subject  of  microscopv  in  questions  of  diagnosis, 
etc." —  Virginia  Medical  Monthly. 

"  We  are  glad  to  see  that  a  good  translation  of 
this  valuable  little  book  has  "been  made.  The 
author  is  well  known  for  his  original  work,  and  we 
can  feel  assiu^ed  that  what  he  writes  must  have 
come  from  practical  experience  in  the  laboratory 
and  is  not  simply  a  product  of  the  '  library  table!' 
.  .  .  It  Ls  not  intended  as  a  treatise  in  pathological 
histology,  but  rather  as  a  practical  guide,  and  as 
such  we  can  most  heartily  recommend  it." — Boston 
Medical  and  Surgical  Journal. 


GAMGEE.     Yellow  Fever  a  Nautical  Disease.      Its  Origin  and 
Prevention.     By  Johx  (jaiigee.     8vo.     207  pages.     Cloth,  $1.50. 


"  The  author  discusses,  with  a  vast  array  of 
clear  and  well-digested  facts,  the  nature  and  pre- 
vention of  yellow  fever.  The  work  is  admirably 
written,  and  the  author's  theories  plausible  and 
well  sustained  by  lo!:rical  deductions  from  estab- 
lished facts." — Homaopathic  Times. 


"  The  theory  is  certainly  shown  to  be  a  plausible 
one ;  and  every  reader,  whether  he  be  con\-inced 
or  not,  can  not  but  be  interested,  instructed,  and 
set  to  thinking." — Lancet  and  Clinic. 


GARMANY.  Operative  Surgery  on  the  Cadaver.  By  Jasper 
Jewett  Garmant,  a.  M.,  M.  D.,  F.  R.  C.  S.,  Attending  Surgeon  to  Out- 
door Poor  Dispensary  of  Bellevue  Hospital ;  Visiting  Surgeon  to  Ninety- 
ninth  Street  Reception  Hospital ;  Member  of  the  British  Medical  Asso- 
ciation, etc.  Small  8vo.  150  pages.  With  Two  Colored  Diagrams 
showing  the  Collateral  Circulation  after  Ligatures  of  Arteries  of  Arm, 
Abdomen,  and  Lower  Extremity.     Cloth,  $2,00. 


"  To  the  more  advanced  student  who  has  the 
opportunity  of  operating  on  the  cadaver,  this  work 
will  be  of  sreat  value,  since  it  reduces  to  a  system 
the  procedm-e  of  ordinary  surgical  operations.  To 
the  practitioner  it  will  be  valuable  as  a  work  of 
easy  reference  as  to  the  best  methods  of  operation. 
In  fact,  it  should  have  been  named  a  manual  of 
surgical  operations.  The  instructions  given  are 
full,  yet  very  plain  and  concise,  and  we  predict  for 
it  a  wide  circulation." — Peoria  Medical  Monthly. 

"...  In  its  necessarily  limited  scope  it  is 
above  criticism.  .  .  .  Indeed,  there  is  nothing 
superfluous  in  the  book,  and  the  busy  practitioner, 
who  must  do  more  or  less  surgery,  would  find  it  a 
very  useful  manual  for  frequent  reference." — Medi- 
cal Press  of  Western  Sew  YorTc. 

"...  For  the  student  in  the  dead-room,  or 
the  busy  operating  surgeon,  this  book  is  one  of 
the  most  reliable  and  handy  works  we  have  ever 
seen." — Southern  Clinic. 

"  Post-mortem  surgery  must  always  precede  in- 
telligent and  successful  surgery.  No  more  accept- 
able or  useful  ffuide  to  this  form  of  experimental 
teaching  could  be  desired  than  the  admirable  little 
work  before  us.     I\ot  a  superfluous  phrase  and  not 


an  obscure   phrase  mars  its  pages.  .  .  .  ''''—New 
England  Medical  Gazette, 

'' .  .  .  No  space  is  wasted,  either  by  words  or 
by  illustrations,  a  fact  which  we  believe  greatly 
enhances  its  value  for  the  earnest  student." — 
Pacific  Medical  and  Surgical  Journal  and  Western 
Lancet. 

"...  All  the  ordinary  operations  practiced  in 
surgerj-  are  described  in  a  concise  and  clear  man- 
ner, many  of  the  later  procedures  finding  a  place 
which  are  not  incorporated  in  larger  works  on 
surgery  akeady  before  the  public.  The  book  will 
prove  to  be  a  great  convenience  to  the  practitioner 
in  active  work,  as  well  as  to  the  student  in  the  dis- 
secting-room."—  WeeJclij  Medical  Review. 

"  This  book  contains  a  simple  and  clear  state- 
ment of  the  way  in  which  a  large  number  of  opera- 
tions are  to  be  performed  on  the  cadaver,  and  can 
be  recommended  to  the  use  of  teachers  and  students 
in  this  important  part  of  a  surgical  education.  .  .  ." 
— Medical  and  Surgical  RepoHer. 

"It  is  well  fitted  to  be  a  text-book  for  classes 
on  operative  surgery.  .  .  .  As  a  manual  it  is  ex- 
cellent."— Philadelphia  Medical  Times. 


20 


D.  APPLETOS  &    CO:S  ILLUSTRATED 


GERSTER.    The  Rules  of  Aseptic  and  Antiseptic  Surgery.    A 

Practical  Treatise  for  the  Use  of  Students  and  the  General  Practitioner. 
By  Arpau  G.  Gkrster,  M.  D.,  Professor  of  Surgery  at  the  New  York 
Polyclinic  ;  Visiting  Surgeon  to  the  German  Hospital  and  to  Mount  Sinai 
Hospital,  New  York.  8vo.  Second  edition.  Illustrated  with  Two  Hun- 
dred and  Forty-eight  Fine  Engravings.     Cloth,  $5.00  ;  sheep,  $6.00. 


"  Messrs.  D.  Appletoii  &  Co.  have  rarely  or 
never  produced  so  strikiiitrly  picturesque  and  at- 
tractive a  work  upon  any  meilical  subject  as  this 
latest  contribution  to  tlie'  exposition  of  the  princi- 
ples of  asepsis  and  antisepsis  in  their  various 
interestinir  applications  to  surijery.  It  is  but 
necessary  to  open  the  volume  and  turn  over  a  tew 
pages  to  become  thorouj;;hl\-  and  deeply  interested. 
Each  step  of  many  of  the  most  important  opera- 
tions of  modern  surgery  is  rej^roduced  in  lifelike 
form  throueh  the  medium  ot  i)hototypoo:raphy, 
which  is  enlianccd  in  etfect  by  tne  beautiful  type 
and  paper  which  have  been  selected  as  media  tor 
the  production  of  the  most  etfective  artistic  results. 


'I'o  this  let  us  add  that  the  object  of  the  volume  is 
a  systematic  vct  practical  jirescntation  of  the  Lis- 
tenan  piTnciple.  which  has  revolutionized  surgery 
within  the  last  fifteen  years.  .  .  .  Every  surgeon, 
interested  in  the  most  advanced  operative  proced- 
ures of  the  day,  accompanied  witli  the  most  scien- 
tific precautionary  aseptic  and  antiseptic  measures 
of  conservative  surgery,  should  possess  this  beau- 
tiful and  thorough  work  of  Dr.  Gerster.  It  beai-s 
the  stamp  on  every  page  of  conscientious  surgical 
knowledge  and  skill,  tender  regard  for  the  patient's 
safety,  and  a  true,  manly  sense  of  the  duties  of  the 
operator." — College  and  Cliidcal  Record. 


Specimen  of  iLLrsTP.ATioN. 


"  Just  such  books  as  this 
are  needed  to  exjiound  the 
pnnciples  of  asepsis,  while 
demonstrating  the  mdhods 
by  which  it  may  be  attained. 
The  former  remain  in  the 
exact  position  to  which  Mr. 
Joseph  Lister  assigned  them  ; 
the  latter  have  changed,  and 
probably  will  change  to  the 
end  of  lime. 

•'  It  is  a  difficult  matter  to 
find  auvthiug    in   this   mag- 


(     '"^ 


"If  ever 
there  was  a 
timely  book 
written  this 
is    it.    .    .    . 

We  need  say  notLing  more  of  thi.'- 
volume  than  we  have  already  said 
to  ajisure  our  readers  that  it  is  one 
of  remarkable  value.  If  it  ha*  its 
equal  anywhere  we  are  not  aware 
of  it.  If  anything  is  needed  to  make  the  author's 
reputation,  this  book  will  do  it,  as  it  will  most 
surely  find  its  way  into  every  town,  villaore,  and 
hamlet  in  our  broad  land.  .  . "." — Sorth  Carolina 
Medical  Journal. 

"  This  is  as  beautiful  a  specimen  of  the  book- 
maker's art  as  we  have  seen.  .  .  .  The  beauty  and 
abundance  of  the  illustrations — which  are  photo- 
graphs taken  during  operation — add  greatly  to  the 
practical  value  of  the  work.  In  a  word."  it  is  a 
book  which  every  physician  who  does  any  surgical 
work  ouffht  to  liave.'' — Buffalo  Medical' and  Sur- 
gical Journal. 


1  n  •  1.'  i  '  ok  that  may  be  advci-scly 
ciitioised.  Even  what  may  at  first 
seem  to  be  faults  'such  as  recom- 
mending the  incision  at  an  early 
date  of  all  phlegmons,  and  advo- 
cating the  etherization  of  diphtheritic 
patients  and  destroying  the  exuda- 
tion with  the  actual  cautery),  the 
I  a  few  years  may  demonstrate  to  be  correct 

j^ractices  driven  to  the  "world  in  advance  of  their 

time." — Pittsburgh  Medical  Review. 

''  The  book  is  an  honest  and  vigorous  exponent 
of  the  doctrines  and  practical  details  of  antiseptic 
surgery,  and.  unlike  too  manv  modem  works  in 
medicine,  is  strikinglv  originiil  in  design  and  exe- 
cution. The  illustrations,  of  which  there  are  two 
hundred  and  fifty-one,  constitute  a  novel  feature  in 
book-making.  They  are  in  most  instances  a  re- 
production of  photographic  views  of  the  author 
and  his  assistants  at  work  in  the  surgical  clinic. 
They  are  admirably  executed,  and,  while  serving 


CATALOGUE   OF  MEDICAL   WORKS. 


21 


to  illustrate  disease,  wounds,  the  author's 
method  of  operating  for  their  relief,  and  his 
armamentarium,  many  of  them  would  make 
excellent  studies  for  the  realistic  artist.  As 
a  specimen  of  the  book-maker's  art  tJie 
volume  is  exquisitely  beautiful." — American 
Practitioner  and  Neivs. 

"...  The  book  may  be  termed  a  treatise 
on  operative  sursrical  physiology  and  pa- 
thology, if  there  be  no  contradiction  in  this 
combination  of  words.  Or,  it  may  be  said 
that  the  book  is  a  series  of  illustrative  ser- 
mons on  the  text.  The  surgeon''s  act  de- 
termines the  fate  of  a  fresh  ivound,  and  its 
infection  and  suppuration  are  due  to  his 
technical  faults  of  omission  and  commission. 
.  .  .  " — Journal  of  the  Am,erican  Medical 
Association. 

"  The  title  of  this  magnificent  book  gives 
no  adequate  idea  of  its  contents.  .  .  .  The 
methods  of  operating  are  those  most  approved 
by  the  best  surgeons  living,  and  are  described 
in  a  thoroughly  lucid  manner.  ...  It  is  no 
small  addition  to  the  value  of  the  text  of  Dr. 
Gerster's  book  that  the  illustrations  of  it  are 
of  a  very  high  order  of  excellence.  .  .  .  The 
work  of  the  publishers,  in  preparing  this 
book,  is  as  creditable  to  them  as  is  that  of 
the  author  to  him,  .  .  .  and  we  can  and  do 
recommend  it  very  strongly  to  our  readers,  as 
■we  feel  that  it  is  a  book  which  ought  to  be  in 
the  hands  of  every  practicing  surgeon." — Medical 
and  Sui'gical  Reporter. 


Specimen  of  Illusteation. 


"  This  is  an  ele- 
gant work,  and  as 
valuable  as  it  is 
beautitul.  Profusely 
jllu--trated,  printed 
from  large,  clear 
type  on  excellent 
calendered  paper, 
and  carefully  edited. 
This  work  brings  surgery  up  to  the  present  mo- 
ment."— Southern  Clinic. 


GROSS.  A  Practical  Treatise  on  Tumors  of  the  Mammary 
Gland  :  embracing  their  Histology,  Pathology,  Diagnosis,  and  Treat- 
ment. By  Samuel  W,  Gross,  A.  M.,  M.  D.,  Surgeon  to,  and  Lecturer  on 
Clinical  Surgery  in,  the  Jefferson  Medical  College  Hospital  and  the  Phila- 
delphia Hospital,  etc.  In  one  handsome  8vo  vol.  of  246  pages.  With  29 
Illustrations.     Cloth,  $2,50. 


Specimen  or  Illustration. 


GiAXT-nELLED  Sakcom A.— Showin?  the  cliaraeteristic  multinucleated  elements 
contained  in  a  stroma  of  spindle  cells,  transverse  secti:)ns  of  which  are  seen  at  the 
upper  corner  to  the  right  of  the  flg-ure. 

"  This  book  is  area!  contribution  to  our  profes- 
sional literature  ;  and  it  comes  from  a  source  which 
commands  oar  re^^pect.  The  plan  is  verv  systematic 
and  comnlete,  and  the  student  or  practitioner  alike 
will  find  e.xactlv  the  information  he  seeks  upon  any 
of  the  diseases  which  are  incident  to  the  mammary 
gland." — Obstetrical  Gazette. 


"  We  know  of  no  book 
in  the  English  language 
which  attempts  to  cover  the 
ground  covered  by  this  one 
— i.ncleed,  the  author  seems 
to  be  the  first  who  has 
souuht  to  handle  the  whole 
subject  of  mammary  tumors 
m  one  systematic  treatise. 
How  he  has  succeeded  will 
best  be  seen  by  a  study  of 
the  book  itself.  Id  the  early 
chapters  the  classification 
and  relative  frequency  of 
the  various  tumors,  their 
evolution  and  transforma- 
tions, and  their  ffitiology, 
are  dealt  with  ;  then  each 
class  is  studied  in  a  separate 
chapter,  in  which  the  re- 
sult of  the  author's  work  is 
compared  with  that  of 
others,  and  the  general  con- 
clusions are  drawn  which 
give  to  the  book  its  great 
practical  value  ;  finally ,'a  chapter  is  devoted  to  di- 
asrnosis,  one  to  treatment,  and  one  to  the  tumors  in 
the  mammary  gland  of  the  male. "— i\'(??p  York 
Medical  ■Journal. 

"  Altogether,  the  work  is  one  of  more  than 
ordinary  interest  to  the  surgeon,  gynecologist,  and 
physician." — Detroit  Lancet. 


22  f>-   APPLET  ON  &    CO:S  ILLUSTRATED 

GRUBER.    A  Text-Book  of  the  Diseases  of  the  Ear.     By  Dr. 

Josef  Gruber,  Professor  of  Otology  in  the  Imperial  Royal  University 
of  Vienna.  Translated  from  the  second  German  edition  by  special  per- 
mission of  the  Author,  and  edited  by  Edward  Law,  M.  D.,  C.  M.,  Edin., 
M.  R.  C.  S.,  Eng.,  and  by  Coleman  Jewell,  M.D.,  C.  M.,  Edin.,  M.  R.  C.  S., 
Eiig.  With  150  IHustrations  and  70  Colored  Figures  on  Two  Litho- 
graphic Plates.     8vo,  580  pages.     Cloth,  85.00. 

'"■  The  book  is  prominent,  if  not  pre-eminent,  "  In  general,  the  work  meets  the  needs  of  ad- 
amonir  an  array  of  excellent  works.  In  this  char-  vanced  medical  students  and  those  engaged  in  the 
acter  of  literature  it  is  destined  long  to  stand  as  study  of  the  ear.  Accomplished  specialists  will  be 
a  monumental  landmark.  Its  character  is  such  glad  to  have  Gruber's  own  views  convenient  of 
that  it  may  not  only  be  relied  on  by  specialists,  but  access,  while  those  engaged  in  mastering  the  intri- 
niay  be  appealed  to  with  confidence  and  satisfac-  cate  details  of  this  branch  of  medicine  will  have  a 
tion  by  tlic  general  practitioner,  who  is  not  infre-  trustwortiiy  and  attractive  guide  thereto.  The 
quently  called  upon  to  correct  disorders  of  this  illustrations  are  numerous,  accurate,  and  well  ex- 
part  of  the  human  anatomy.  The  subjects' coming  ecuted,  especially  the  chromo-lithographs  of  the 
•within  tiie  scope  of  the  work  have  been  dealt  with  different  appearances  of  the  membraua  tympani." 
in  every  detail,  and  the  book  is  profusely  and  ex-  — American  Lancet. 
cellently  illustrated." — Pacijic  Medical  Journal. 

HAMMOND.  Clinical  Lectures  on  Diseases  of  the  Nervous  Sys- 
tem. Delivered  at  the  Bellevue  Hospital  Medical  College.  By  Will- 
iam A.  Hammoxd,  M.  D.,  Professor  of  Diseases  of  the  Mind  and  Nervous 
System,  etc.  Edited,  with  Notes,  by  T.  M.  B.  Cross,  M.  D.,  Assistant  to 
the  Chairs  of  Diseases  of  the  Mind  and  Nervous  System,  etc.  In  one 
handsome  volume  of  300  pages.     §3.50. 

These  lectures  have  been  reported  in  full,  and,  together  with  the  histories  of  the  cases,  which  were 
prepared  by  the  editor  after  careful  study  and  prolonged  observation,  constitute  a  clinical  volume 
which,  while  it  does  not  claim  to  be  exhaustive,  will  nevertheless  be  found  to  contain  many  of  the  more 
important  affections  of  the  kind  that  are  commonly  met  with  in  practice. 

As  these  lectures  were  intended  especially  for  the  benetit  of  students,  the  author  has  confined  him- 
self to  a  full  consideration  of  the  symptoms,  causes,  and  treatment  of  each  affection,  without  attempting 
to  enter  into  the  pathology  or  morbid  anatomy. 

HAMMOND.  A  Treatise  on  Insanity,  in  its  Medical  Relations.  By 
William  A.  Hammond,  M.  D.,  Surgeon-General  U.  S.  Army  (retired  list); 
Professor  of  Diseases  of  the  Mind  and  Nervous  System  in  the  New  York 
Post-Graduate  Medical  School  ;  President  of  the  American  Neurological 
Association,  etc.     8vo.     767  pages.     Cloth,  $5.00;  sheep,  86.00. 

In  this  work  the  author  has  not  only  considered  the  subject  of  Insanity,  but  has  prefixed  that  division 
ot  his  work  with  a  general  view  ot  the  mind  and  the  several  categories  of  mental  foculties  and  a  full 
account  of  the  various  causes  that  exercise  an  influence  over  mental  derani^ement  such  as  habit  ace  sex 
hereditary  tendency,  constitution,  temperament,  instinct,  sleep,  dreams,  and  manv  other  factors  '^  '     '  ' 

Insanity,  it  is  believed,  is  in  this  volume  brought  before  the  reader  in  an  oriirinal  manner  and  with 
a  desriee  otthorouirhness  which  can  not  but  lead  to  important  results  in  the  studv  of  psvcholoaical 
medicine  Those  lorms  which  have  only  been  incidentally  alluded  to  or  entirely  disre'o-arded  'in  the  text- 
books hitherto  pubhsued  are  here  shown  to  be  of  the  srreatest  interest  to  the  general  practitioner  and 
student  ol  mental  science,  both  from  a  normal  and  abnormal  standpoint.  To  a  ^rcat  extent  the  work 
relates  to  those  species  ot  mental  derangement  which  are  not  seen  within  asvlum  walls  and  which 
therefore,  are  of  special  importance  to  the  non-asylum  physician.  Moreover,  'it  points  out  the  symp- 
toms ot  Insanity  m  its  first  stages,  dunng  which  there  is  most  hope  of  successful  medical  treatment, 
ana  beiore  the  idea  ot  an  asylum  has  occurred  to  the  patient's  friends. 

"  Dr.  Hammond  is  a  bold  and  strong  writer,  to   the   lon<r   list   of  valuable   publications  which 

has  given  much  study  to  this  subject,  and  expresses  have  placed  him  amontr  the  foremost  neuroloo-ists 

hunselt  so  as  to  be  understood  by  the  reader,  even  and  alienists  of  America ;  and  we  predict  for^this 

It  the  latter  does  not  coincide  with  him.     We  like  volume  the  happy  fortune  of  its  predece«^oi-s— a 

the  book  very  much,  and  consider  it  a  valuable  rapid  iournev  thfou(^h   pavin<r  editions      We  are 

addition  to  the  literature  of  insanity.     We  have  no  sorry  that  our  limits  will  not  permit  of  an  analysis 

hesitancy  in  commendina  the  book  to  the  medical  of  this  work,  the  best  text-book  on  insanity  that 

protesMon,   a^   it   is   to   them   it  is  specially   ad-  has  yet  appeared."— 7%e  Poh/clinic. 
dressed.^'—  Tkerapeutic  Gazette.  '' 

,,,,,.  1,1,,  ,  "We  are  ready  to  welcome  the  present  volume 

i:)r.  Hammond  has  added  another  great  work  as  the  most  lucid,  comprehensive,  and   practical 


CATALOGUE  OF  MEDICAL   WORKS. 


23 


exposition  on  insanity  that  has  been  issued  in  this 
country  by  an  American  alienist,  and,  furthermore, 
it  is  the  most  instructive  and  assimilable  that  can 
be  placed  at  present  in  the  hands  of  the  student 
iminitiated  in  psychiatry.  The  instruction  con- 
tained within  its 'pages  is  a  food  thoroughly  pre- 
pared for  mental  digestion  ;  rich  in  the  condiments 
that  stimulate  the  appetite  for  learning,  and  sub- 
stantial in  the  more  solid  elements  that  enlarge 
and  strengthen  the  intellect." — New  Orleans  Medi- 
cal and  Sui'gical  Journal. 

"This  is  the  first  systematic  attempt,  we  be- 
lieve, to  describe  all  the  various  forms  of  medical 
insanity  by  their  clinical  features,  and  the  work  is 
destined  to  rank  far  above  the  few  treatises  that 
are  already  recognized  as  authorities  on  the  sub- 


ject. In  the  consideration  of  insanity  every  author 
has  his  own  pet  classification ;  but  Dr.  Hammond's, 
being  based  upon  clinical  manifestations,  is  more 
complete,  more  philosophical,  and  less  complex 
than  any  that  we  remember  to  have  seen.  The 
least  we  can  say  is,  that,  although  we  differ  from 
the  author  in  some  of  his  conclusions,  we  i-arely 
have  the  privilege  to  read  a  book  containing  so 
much  originality  and  giving  so  lasting  a  satisfac- 
tion as  this.  So  perfectly  natural  is  "the  style  of 
composition  that  one  feels  as  if  he  were  reading  a 
fascinating  novel  instead  of  a  medical  treatise,  and 
the  whole  book  will  interest  not  only  the  non- 
medical reader,  but  also  the  alienist  and  general 
practitioner." — International  Review  of  Medical 
and  Surgical  Technics. 


Specimen  of  Illusteation. 


^?^Ttl 


HAMMOND.  A  Treatise  on  the  Diseases  of  the  Nervous  Sys- 
tem. By  William  A,  Hammond,  M.  D.,  Surgeon-General  U.  S.  Army 
(retired  list);  Professor  of  Diseases  of  the  Mind  and  Nervous  System 
in  the  New  York  Post-Graduate  Medical  School  and  Hospital ;  Member 
of  the  American  Neurological  Association  and  of  the  New  York  Neu- 
rological Society  ;  of  the  New  York  County  Medical  Society,  etc.  With 
118  Illustrations.  Ninth  edition,  revised,  corrected,  and  enlarged  by  the 
Addition  of  a  New  Section  on  Certain  Obscure  Nervous  Diseases.  8vo. 
932  pages.     Cloth,  $5.00  ;  sheep,  $6.00. 

The  work  has  received  the  honor  of  a  French  translation  by  Dr.  Labadie-Lagrave,  of  Paris,  and  an 
Italian  translation,  by  Professor  Diodato  Borrelli,  of  the  Eoyal  University,  has  gone  through  the  press 
at  Naples. 

"  In  the  Buddhist  faith  the  eight 
gates  of  purity  are  described  as:  1. 
Correct  ideas  ;  2.  Correct  thoughts  ; 
3.  CoiTcct  words;  4.  Correct  works; 
5.  Correct  life  ;  6.  Correct  endeav- 
ors ;  7.  Correct  judgment ;  and  8. 
Correct  tranquillity.  If  Dr.  Ham- 
mond has  not  attained  the  medical 
nirvana,  and  passed  those  eight 
gates  of  purity,  he  has  at  least 
realized  the  Buddhist  beatitude : 
'Much  in  sight  and  education, 
self-control  and  pleasant  speech ; 
and  whatever  word  be  well  spoken, 
this  is  the  greatest  blessing.'  At 
least,  the  thoughts  and  utterances 
of  Dr.  Hammond  have  been  so  ad- 
preciated  by  the  medical  profession 
of  America  and  England  that  the 
work  has  already  passed  through 
eight  editions  since  its  first  ap- 
pearance in  1871.  As  now  revised 
by  the  author  and  published  by 
the  Appletons,  it  constitittes  de- 
cidedly the  best  work  in  the  Eng- 
lish lauguacre  upon  diseases  of  the 
nervous  system."  —  Kansas  City 
Medical  Index. 

"  This  excellent  work  has  now 
been  fifteen  years  before  the  pro- 
fession, its  popularity  being  suffi- 
ciently evidenced  by  the  fact  that  it 
has  rapidly  passed  through  eight 
editions."  —  College  and  Clinical 
Becord. 

"  This  volume  has  been  received  bjr  the  profes-  tains  a  section  on  '  Certain  Obscure  Diseases  of  the 

sion  '  to  an  extent  beyond  that  ever  given  to  any  Nervous  System,'  is  thoroughly  revised  throuo^h- 

other  work  of  like  scope  and  objects  published  in  out,  and  several  changes  made,  thereby  increasing 

any  part  of  the  world.'     The  present  edition  con-  greatly  its  usefulness." — Buff.  Med.  and  Sur.  Jour. 


24 


D.  APPLET  ON  &    CO:S  ILLUSTRATED 


HARVEY.  First  Iiines  of  Therapeutics  as  Based  on  the  Modes  and 
the  Processes  of  Healing,  as  occurring  spontaneously  in  Diseases  ;  and  on 
the  Modes  and  the  Processes  of  Dying  as  resulting  naturally  from  Disease. 
In  a  Series  of  Lectures.  By  Alexander  Haryet,  M.  A.,  M.  D.,  Emeri- 
tus Professor  of  Materia  Medica  in  the  University  of  Aberdeen,  etc.,  etc. 
12mo.     278  pages.     Cloth,  $1.50. 

"If  onlv  it  can  get  a  fair  heariiiir  before  the  "We  may  say  tliat,  as  a  contribution  to  the 
profession  it  will  be  the  means  of  aiding  in  the  philosophy  of  medicine,  this  treatise,  which  may 
development  of  a  therapeutics  more  rational  than  be  prottably  read  during  odd  moments  of  leis- 
we  now  dream  of  To  medical  students  and  ure,  has  a  happy  method  of  statement  and  a  re- 
practitioners  of  all  sorts  it  will  open  up  lines  of  freshing  freedom  from  dogmatism." — JS'ew  York 
thought  and  investigation  of  the  utmost  moment."  Medical  Record. 
Detroit  Lancet. 


HOFMANN  AND  ULTZMANN.  Analysis  of  the  Urine,  with 
Special  Reference  to  the  Diseases  of  the  Genito-Urinary  Organs.  By  K. 
B.  HoFMANN,  Professor  in  the  University  of  Gratz,  and  R.  Ultzmann, 
Docent  in  the  University  of  Vienna.  Translated  by  T.  Barton  Brune, 
A.  M.,  M.  D.,  late  Professor  of  the  Practice  of  Medicine  in  the  Baltimore 
Polyclinic  and  Post-Graduate  Medical  School,  etc.,  and  II.  Holbrook 
Curtis,  Ph.  B.,  M.  D.,  Fellow  of  the  New  York  Academy  of  Medicine, 
etc.  Third  edition,  revised  and  enlarged.  With  8  Lithographic  Plates. 
Svo.     310  pages.     Cloth,  12.00. 

They  have  done  their  work  well,  and  in  this  vol- 
ume present  the  profession  with  a  reliable,  prac- 
tical book,  giving  the  most  advanced  ideas  as  to 
urinalysis  .-rnd  diagnosis  of  urinary  troubles  in 
simple  languacfe,  which  does  not  require  a  mastery 
of  clinical  tecTinology  to  understand." — Virgirvta 
Medical  Montlily. 


"  Ilofmann  and  Ultzmann's  popular  work  on  the 
urine  needs  neither  criticism  nor  recommendation 
Its  claims  have  been  substantiated  in  the  offices  of 
thousands  of  physicians  both  in  Europe  and 
America.  It  covers  the  entire  field  of  chemical 
and  microscopical  examination  of  urine  so  far  as 
diagnosis  is  concerned,  giving  explicit  directions  as 
to  details  of  manipulation." — Hahnemannian. 

"  Possessed  of  this  book,  a  few  reagents,  a  mi- 
croscope with  glasses  powerful  enough  to  magnify 
two  or  three  hundrea  diameters,  and  a  few  test- 
tubes  and  slides,  tliere  is  no  good  reason  why  every 
physician  should  not  become  a  good  urinary  ana- 
lyst."— Mississippi  Valley  Medical  Monthly. 

"  For  the  every-day  wants  of  the  practitioner, 
we  know  of  no  rnanual  on  urinary  analysis  that 
equals  Hofmann  and  Ultzmann's  work.  .  .  .  The 
second  edition  contains  all  tlie  important  advances 
that  have  been  made  in  the  examination  of  the 
urinary  constituents  durinsr  the  past  three  years 
One  of  the  most  important  sections  ot  the  work  is 
that  devoted  to  an  account  of  the  microscopical 
and  clinical  aids  for  the  diagnosis  of  the  different 
forms  of  albuminuria.  The  translators  are  to  be 
conyratulated  on  producing  a  very  clear  and  read 
able  rendering  of  the  origmal." — Canada  Medical 
and  Surgical  Journal. 

"The  second  edition  of  this  classical  work  on 
the  urine  will  be  welcomed  as  containing  all  the 
latest  advances  in  urinary  analysis.  All  unneces- 
sary matter  has  been  eliminated,  and  the  chem- 
istry is  so  simple  as  to  be  within  the  comprehension 
of  all.  The  translators  have  made  a  few  additions 
which  are  practical  and  therefore  useful." — Canada 
Lancet. 

"  This  work  has  Ions:  been  standard  authority 
But  the  late  advances  in  urinology  have  made  it 
necessary  for  the  American  translators  practicall\- 
to  become   editors   of  a   new  or  second  edition. 


"  In  the  present  edition  all  unnecessary  matter 
has  been  eliminated,  and  the  translators  have  in- 
coi"porated  all  that  has  recently  been  added  to  our 
knowledge  of  the  subject  that  will  be  of  especial 
interest  to  the  student  and  practitioner.  A  valu- 
able feature  of  the  book  is  the  illustrations,  which 
are  very  fine  indeed." — Indiana  Medical  Journal. 

"Students  and  general  practitioners  can  ask 
no  better  working  guide  on  the  subjects  treated 
than  this  standard  work.  The  publishers  present 
it  in  a  handsome  and  durable  form,  and  the  colored 
plates  are  uncommonly  finished  and  fine." — Sew 
England  Medical  Gazette. 

"  That  this  work  is  a  valuable  and  practical  one 
is  attested  by  its  continued  popularity.  It  is  not  a 
mere  compilation  of  the  work  of  others,  but  con- 
tains the  result  of  years  of  careful  research.  It 
gives  many  details  that  will  be  found  most  helpful 
to  students  of  urinary  analysis  as  well  as  to  treneral 
practitioners.  The  litliograpliic  plates  at  the  end 
are  very  accurate.  The  book  ranks  au)ong  the 
best  of  its  kind,  and  we  can  heartily  commend 
it." — Medical  Record. 

"  This  is  a  translation  of  a  work  well  known 
abroad.  It  is  intended  as  a  hand-book  for  student 
and  practitioner,  and  contains  many  valuable 
suggestions  and  practical  hints  both  as  regards 
analysis  and  diagnosis.  The  iirofession  is  under 
especial  obligations  to  the  able  translators  for 
smooth  and  elegant  translation  from  the  Germim. 
The  work  will  certainly  obtain  a  large  share  of 
fiivorable  attention." — A'ashril/e  Journal  q/  Medi- 
cine. 


CATALOGUE  OF  MEDICAL   WORKS. 


25 


HOWE.  Emergencies,  and  How  to  treat  Them.  The  Etiology, 
Pathology,  and  Treatment  of  Accidents,  Diseases,  and  Cases  of  Poison- 
ing, which  demand  Prompt  Action.  Designed  for  Students  and  Practi- 
tioners of  Medicine.  By  Joseph  W.  Howe,  M.  D.,  Clinical  Professor  of 
Surgery  in  the  Medical  Department  of  the  University  of  New  York,  etc., 
etc.     Fourth  edition,  revised.     8vo.     265  pages.     Cloth,  $2.50. 

book  we  recommend  it  most  heartily  to  the  profes- 
sion."— Boston  Medical  and  Surgical  Journal. 

"  This  work  bears  evidence  of  a  thorough  prac- 
tical acquaintance  with  the  different  branches  of 
the  profession.  The  author  seems  to  possess  a 
peculiar  aptitude  for  imparting  instruction  as  well 
as  for  simplifying  tedious  details.  A  careful  peru- 
sal will  amply  repay  the  student  and  practitioner." 
— JVew  York  Medical  Journal. 


"  To  the  general  practitioner  in  towns,  villages, 
and  in  the  country,  where  the  aid  and  moral  sup- 
port of  a  consultation  can  not  be  availed  of,  this 
volume  v/ill  be  recognized  as  a  valuable  help.  We 
commend  it  to  the  profession." — Cincinnati  Lan- 
cet and  Observer. 

"  The  author  wastes  no  words,  but  devotes  him- 
self to  the  desciiption  of  each  disease  as  if  the  pa- 
tient were  under  his  hands.     Because  it  is  a  good 


HOWE.  The  Breath,  and  the  Diseases  -which  give  it  a  Fetid 
Odor.  With  Directions  for  Treatment.  By  Joseph  W.  Howe,  M.  D., 
Clinical  Professor  of  Surgery  in  the  Medical  Department  of  the  Univer- 
sity of  New  York,  etc.  Second  edition,  revised  and  corrected.  12mo. 
108  pages.     Cloth,  $1.00. 


"  This  little  volume  well  deserves  the  attention 
of  physiciansj  to  whom  we  commend  it  most 
highly." — Chicago  Medical  Journal. 

"  To  any  one  suffering  from  the  affection, 
either  in  his  own  person  or  in  that  of  his  intimate 
acquaintances,  we  can  commend  this  volume  as 
containing  all  that  is  known  concerning  the  sub- 


ject, set  forth  in  a  pleasant  style. "- 
Medical  Times. 


-Philadelphia. 


"  The  author  gives  a  succinct  account  of  the  dis- 
eased conditions  in  which  a  fetid  breath  is  an  im- 
portant symptom,  with  his  method  of  treatment. 
We  consider  the  work  a  real  addition  to  medical 
literature."  —  Cincinnati  Medical  Journal. 


HTJEPPE.    The  Methods  of  Bacteriological  Investigation.    By 

Ferdinand  Hueppe,  Docent  in  Hygiene  and  Bacteriology  in  the  Chemical 
Laboratory  of  R.  Fresenius,  at  Wiesbaden.  Written  at  the  request  of 
Dr.  Robert  Kooh.  Translated  by  Hermann  M.  Biggs,  M.  D.,  Instructor 
in  the  Carnegie  Laboratory,  and  Assistant  to  the  Chair  of  Pathological 
Anatomy  in  Bellevue  Hospital  Medical  College.  8vo.  218  pages.  With 
31  Illustrations.     Cloth,  $2.50. 

choice  of  author,  and  is  one  which  no  student  of 
pathology  can  afford  to  be  witliout.  The  transla- 
tion seems  to  have  been  most  acceptably  made." — 
Medical  Press  of  Western  New  York. 


"  This  is  the  best  book  so  far  available  in  Eng- 
lish, being  better  adapted  to  the  general  student 
who  undertakes  the  study  from  first  principles." — 
North  Carolina  Medical  Journal. 

"  All  students  of  bacteriology  will  at  once  place 
this  volume  on  their  tables  as  indispensable  for  their 
most  accurate  and  rapid  study." — American  Lancet. 

"  The  work  is  written  by  one  who  thoroughly 
understands  his  subject  and  puts  it  clearly  before 
the  student." — Pacific  Medical  and  Surgical  Jour- 
nal and  Western  Lancet. 

"He  has  sifted  the  whole  of  the  scattered  and 
sometimes  almost  inaccessible  literature  of  the  sub- 
ject, and  has  furnished  the  independ.-nt  investi- 
gator a  most  valuable  book,  useful  alike  to  the 
practitioner  and  to  the  student,  as  a  trustworthy  in- 
troduction into  this  territory." — College  and  Clini- 
cal Record. 

"  To  those  who  wish  to  have  more  than  a  mere 
theoretical  knowledge  of  the  subject  the  manual 
Will  be  found  indispensable." — Medical  Record. 

"  As  a  whole,  the  book,  written  at  Professor 
Koch's  request,  reflects   credit  on    the  master's 


"  Of  the  many  works  that  have  recently  ap- 
peared on  the  subject  of  bacterial  technology,  this 
one  certainly  meets  the  requirements  of  a  practical 
guide  and  book  of  reference  ;  .  .  .  the  merits  of  the 
work  are  decided  and  should  secure  for  it  the  repu- 
tation it  deserves." — Atlanta  Medical  and  Surgi- 
cal Journal. 

"The  book  treats  the  subject  in  an  exceedingly 
clear  and  comprehensive  manner,  and  leaves  little 
to  be  desired  by  the  beginner,  and  is  a  complete 
guide  to  those  wishing  to  work  out  any  of  the  in- 
numerable problems  connected  with  the  life-history 
of  the  bacteria.  .  .  .  The  translation  seems  to  be 
well  done." — American  Journal  of  the  Medical 
Sciences. 

"  The  importance  of  this  subject  in  the  scientific 
world  ...  should  insure  for  so  practical  a  presen- 
tation of  it  as  is  found  in  the  present  volume  a  wide 
popularity." — New  England  Medical  Gazette. 


26  D.  APPLET  ON  &   CO:S  ILLUSTRATED 


HUXLEY.  The  Anatomy  of  Vertebrated  Animals.  By  Thomas 
Henry  Huxley,  LL.  D.,  F.  R.  S.  12mo.  Illustrated.  431  pages. 
Cloth,  $2.50. 

"  The  present  work  is  intended  to  provide  students  of  comparative  anatomy  with  a  condensed  state- 
ment of  the  most  inniortaut  facts  rehitinir  to  the  structure  of  vertebrated  animals  which  have  hitherto 
been  ascertained.  Tne  Vertehrata  are  distinguished  trom  all  other  animals  by  the  circumstance  that  a 
transverse  and  vertical  section  of  the  body  exhibits  two  cavities  completely  separated  from  one  another 
by  a  partition.  The  dorsal  cavity  contains  the  cerebro-spinal  nervous  system  ;  tlie  ventral,  the  alimen- 
tary canal,  the  heart,  and  usually  a  double  chain  of  gaug-lia,  which  passes  under  the  name  of  the  'sym- 
pat"lietie.'  It  is  probable  that  "this  sympathetic  nervous  system  represents,  wholly  or  partially,  the 
principal  nervous  system  of  the  Annulosa  and  MoUusca.  And,  in  any  case,  the  central  parts  of  the 
cerebro-spinal  nervous  system— viz.,  the  brain  and  the  spinal  cord — would  appear  to  be  unrepresented 
amonic  invertebrated  animals." — The  Author. 

"This  long-e.xpeeted  work  will  be  cordially  equally  out  of  place.  It  is  enough  to  say  that 
welcomed  by  all  students  and  teachers  of  Com-  it  realizes,  in  a  remarkable  degree,  the  anticipa- 
parative  Anatomv  as  a  compendious,  reliable,  and,  tions  which  have  been  formed  of  it ;  and  that  it 
notwithstanding  "its  small  dimensions,  most  com-  presents  an  extraordinary  combination  of  wide, 
prehensive  guide  on  the  subject  of  which  it  treats,  general  views,  with  the  clear,  accurate,  and  sue- 
To  praise  or  to  criticise  the  work  of  so  accom-  cinct  statement  of  a  prodigious  number  of  indi- 
plished  a  master  of  his  favorite  science  would  be     vidual  facts." — ]\'ature. 

JACCOUD.  The  Curability  and  Treatment  of  Pulmonary 
Phthisis.  By  S.  .Jaccoud,  Professor  of  Medical  Pathology  to  the 
Faculty  of  Paris  ;  Member  of  the  Academy  of  Medicine  ;  Physician  to 
the  Lariboisiere  Hospital,  Paris,  etc.  Translated  and  edited  by  Montagu 
Lubbock,  M.  D.  (London  and  Paris),  M.  R.  C.  P.  (England),  etc.  8vo. 
407  pages.     Cloth,  #4.00. 

"  This    is    the    work   of    that    most  eminent 
Frenchman   of  the   £(oh  de  Medecine  of  Paris,  "  M.  Jaccoud,   the   author  of  the   work,  and 

and   the   translation    of  Lubbock  is   strong    and  the  eminent  professor  of  the  £cole  de  Medecine, 

masterly  inasmuch  as  it  e\"idences  the  possession  Paris,  is   generally  recognized   on   the  Continent 

of   a   large   vocabulai7    knowledge    of   both    the  as    one    of   the   t)est    authorities    on    pulmonary 

original  and   English."     No  man   of  the  jDresent  phthisis,  so  that  an  Enijlish  edition  of  his  work 

day,  with  the  sintrle  exception  perhaps  of  Hughes  will  certainly  be  very  acceptable  to  those  inter- 

Bennet,  has  devoted  as  much  careful  study  to  the  ested  in  the  subject.  .  .  .  M.  Jaccoud's  reputation 

climatic   treatment    of   phthisis   as   Dr.    Jaccoud,  is  justly  so  great  that  his  opinions  \yith  respect 

and  his  conclusions  on  this  point  so  far  as   re-  to    the    treatment    will     be    read    with    general 

gards  the  Continent  of  Europe  must  be  deemed  interest." — Texas  Courier- Record  of  Medicine. 
final."  —  Cincinnati  Lancet  and  Clinic. 

JOHNSTON.  The  Chemistry  of  Common  Life,  Illustrated  with 
numerous  Wood  Engravings.  By  the  late  James  F.  W.  Johnson, 
F.  R.  S.,  Professor  of  Chemistry  in  the  University  of  Durham.  A  new 
edition,  revised  and  brought  down  to  the  Present  Time.  By  Arthue 
Herbert  Church,  M.  A,,  Oxon.  Illustrated  with  Maps  and  numerous 
Engravings  on  Wood.     12mo.     592  pages.     $2.00. 

SUMMARY  OF  CONTENTS.— 'Tha  Air  we  Breathe 5  the  Water  we  Drink;  the  Soil  we  Culti- 
vate ;  the  Plant  we  Rear ;  the  Bread  we  Eat ;  the  Beef  we  Cook  ;  the  Beverages  we  Infuse  ;  the  Sweets 
we  Extract;  the  Liquors  we  Ferment;  the  Narcotics  we  Indulge  in;  the  Poisons  we  Select;  the  Odors 
\ve  Enjoy  ;  the  Smells  we  Dislike ;  the  Colors  we  Admire ;  What  we  Breathe  and  Breathe  for;  What, 
How,  and  Why  we  Digest;  the  Body  we  Cherish  ;  the  Circulation  of  Matter. 

JONES.  Practical  Manual  of  Diseases  of  Women  and  Uterine 
Therapeutics.  For  Students  and  Practitioners.  By  H.  Macnaughton 
Jones,  M.  D.,  F.  R.  C.  S.  I.  and  E.,  Examiner  in  Obstetrics,  Royal  Univer- 
sity of  Ireland  ;  Fellow  of  the  Academy  of  Medicine  in  Ireland  ;  and  of 
the  Obstetrical  Society  of  London,  etc.  12mo,  410  pages.  188  Illustra- 
tions.    Cloth,  S3.00. 


ijATALOQUE  OF  MEDICAL   WORKS. 


27 


"  As  a  concise,  well-written,  useful  manual,  we 
■consider  this  one  of  the  best  we  have  ever  seen. 
The  author,  in  the  preface,  tells  us  tiiat  '  this  book 
is  simply  intended  as  a  practitioner's  and  student's 
manual.  I  have  endeavored  to  make  it  as  practical 
in  its  teachinojs  as  possible.'  The  style  is  pleasant 
to  peruse.  The  author  expresses  his  ideas  in  a  clear 
manner,  and  it  is  well  up  with  the  approved  meth- 
ods and  treatment  of  the  day.  It  is  -well  illusti-ated, 
and  due  credit  is  given  to  American  gyntecologists 
for  work  done.  It  is  a  good  book,  well  printed  in 
good,  large  type,  and  well  bound." — Sew  England 
Medical  MontJily. 

"  It  is  seldom  that  we  see  a  book  so  completely 
fin  its  avowed  mission  as  does  the  one  before  us. 
It  is  practical  from  beginning  to  end,  and  can  not 
fail  to  be  appreciated  by  the  readers  for  whom  it  is 
intended.  The  author's  style  is  terse  and  perspicu- 
ous, and  he  has  the  enviable  faculty  of  giving  the 
learner  a  clear  insight  of  his  methods  and  -reasons 
for  treatment.  Prepared  for  the  practitioner,  this 
little  work  deals  only  with  his  every-day  wants  in 
ordinary  family  praatice.  Every  one  is  compelled 
to  treat  uterine  djsease  who  does  any  general  busi- 
ness whatever,  and  should  become  acquainted  with 
the  minor  operations  thereto  pertaining.    The  book 


before  us  covers  this  ground  completely,  and  we 
have  nothing  to  otfer  in  the  way  of  criticism." — 
Medical  Record. 

"  The  manual  before  us  is  not  the  work  of  a 
specialist — using  this  term  in  a  narrow  sense — but 
of  an  author  ali-eady  favorably  known  to  the  stu- 
dents of  current  medical  literature  by  various  and 
comprehensive  works  upon  other  branches  of  his 
profession. .  Nor  is  it,  on  tlie  other  hand,  the  work 
of  an  amateur  or  merely  ingenious  collaborateur, 
for  Dr.  Macnaughton  Jones's  gynecological  expe- 
rience in  connection  with  the  Cork  Hospital  for 
Women  and  the  Cork  Maternity  was  such  as  fairly 
entitles  him  to  speak  authoritatively  upon  the  sub- 
jects with  which  it  deals.  But,  after  so  many  works 
by  avowed  specialists,  we  are  glad  to  welcome  one 
upon  Gynaecology  by  an  author  whose  opportunities 
and  energy  have  enabled  him  to  master  the  details 
of  so  many  branches  of  medicine.  We  are  glad  also 
to  be  able  to  state  that  his  work  compares  very  fa- 
vorably with  others  of  the  same  kind,  and  that  it 
does  admirably  fulfill  the  purposes  with  which  it 
was  written — '  as  a  safe  guide  in  ,  practice  to  the 

Eractitioner,  and  an  assistance  in  the  study  of  this 
ranch  of  his  profession  to  the  student.'  " — Dublin 
Journal  of  Medical  Science. 


KEYES.  A  Practical  Treatise  on  the  Surgical  Diseases  of  the 
Genito-Urinary  Organs,  including  Syphilis.  Designed  as  a  Manual 
for  Students  and  Practitioners.  With  Engravings.  By  E.  L.  Keyes, 
A.  M.,  M.  D.,  Professor  of  Genito-Urinary  Surgery,  Syphilology,  and  Der- 
matology in  Bellevue  Hospital  Medical  College.  Being  a  revision  of  a 
Treatise,  bearing  the  same  title,  by  Vak  Buren  and  Keyes.  Second  edi- 
tion, thoroughly  revised,  and  somewhat  enlarged.  8vo.  688  pages. 
Cloth,  S5.00  ;  sheep,  16.00. 


Specimen  of  Illustration. 


"  Those  who  are  familiar  with  the  older  works 
of  Keyes  (Van  Buren  and  Keyes)  will  scarcely 
recoiinize  the  present  treatise.  Since  1874  the  ad- 
vances in  the  department  of  surgery  included  under 
the  term  genito-urinary  have  been  so  considerable 
that  the  work  before  us  is  practically  a  new  book. 
The  author  appears  to  have  been  prompted  by  feel- 
ings of  reverence  for  his  '  dear  old  master '  in  call- 
ing this  a  revision  of  the  work  alluded   to.     To 


mention  but  a  few  subjects  that  are  essentially  new, 
we  may  allude  to  litholapaxy,  suprapubic  cys- 
totomy (the  modified  and  revised  older  operation), 
renal  surgery,  the  modern  methods  of  dealing  with 
hydrocele,  and  the  radical  cure  of  varicocele.  The 
profession  will  give  glad  and  speedy  welcome  to 
Dr.  Keyes's  treatise  as  it  now  stands.  It  may  well 
challenge  fiivorable  comparison  with  similar  works 
by  other  authors,  and  if  so  examined  it  will  not  be 
found  wantincr  in  all  that  is  essential  to  a  reliable, 
readable,  and  instructive  manual  on  a  highly  impor- 
tant branch  of  the  healing  art." — Medical  Record. 

"  Professor  Keyes  has  done  the  profession  good 
service  in  this  thorough  revision  of  the  original 
work  which  Professor  Van  Buren  and  himself  pre- 
pared, now  many  years  ago.  As  the  latter  states 
in  his  preface,  litholapaxy  has  had  its  birth  since 
that  date,  the  surgery  of  the  kidney  has  been  con- 
structed anew,  and  very  different  views  are  enter- 
tained as  to  the  patholoiry  and  treatment  of  many 
of  the  abnoi-mal  conditions  of  the  genito-urinary 
system.  Thorousrhly  modernized  as  Dr.  Keyes's 
important  work  now  is,  it  will  long  remain  a  monu- 
ment of  the  skill,  originality,  and  tact  of  its  talented 
author." — College  and  Clinical  Record. 

"Dr.  Keyes.  from  his  daily  contact  with  stu- 
dents, knows  their  needs,  and  his  pointed  manner 
of  saying  the  right  thing  shows  that  he  knows  how  to  teach.      To  the  practitioner  also,  who  wants  a 
work  to  which  he  can  refer  at  all  times  with  confidence,  when  seeking  guidance  for  the  proper  man- 


28 


D.  APPLETON  &   CO:S  ILLUSTRATED 


agement  of  an  old  case  of  stone,  or  enlarged  pros- 
tate, or  any  jjenito-urinary  trouble,  we  can  heartily 
recommend  tbis  edition  of  Keyes's  book." — Prac- 
tice. 

"  Professor  Keyes  has  now  become  so  well  and 
favorably  known  it)  connection  with  genito-urinary 
surgery  that  any  work  bearing  his  name  is  suffi- 
ciently recommended,  and  we  are  sure  this  new  re- 
vision of  Van  Buren  and  Reyes's  text-book  is  quite 
up  to  any  work  upon  the  same  subject  heretofore 
produced.  We  can  recommend  it  highly  because 
It  is  a  complete  treatise  of  the  diseases  of  tne  genito- 
urinary system,  including  sypliilis,  and  further,  on 
account  of  the  able  and  practical  manner  with 
which  the  subject  is  handled.  Any  one  who  will 
carefully  read  the  pages  of  tliis  work  will  find  his 
time  has  been  well  spent."— C«?ia</a  Lancet. 

"  The  labors  of  Dr.  Keyes  are  too  well  known 
to  require  further  commendation.  The  last  effort 
is  eminently  lucid  and  practical,  and  is  deserving 
of  general  recognition.  There  are  some  things 
with  which  we  might  feel  disposed  to  differ  witli 
the  author — notably,  treatment  of  syphilis  and 
urethral  stricture — but  the  general  merit  of  the 


production  compels  us  to  refrain  from  criticism.  It 
ought  to  be  in  the  liands  of  every  physician,  for  it 
is  interesting  and  instructive.  The  publishers 
have,  as  usual,  issued  it  in  good  style." — Medical 
and  Surgical  S//nopsii<. 

"  It  is  safe  to  predict  that  no  book  of  the  year 
■will  meet  with  a  more  eager  welcome  than  tliis  re- 
vision by  Dr.  Keyes  of  the  classical  work  of  which 
he  was  joint  autlior.  ...  He  has  virtually  rewrit- 
ten the  book  which  first  gave  him  fame,  bringing 
to  the  work  the  experience  of  added  years  of  active 
labor,  and  the  result  is  a  treati.se  on  the  subject,  of 
which  it  is  not  too  high  praise  to  say  that  it  stands 
witliout  a  peer  in  the  English  language.  It  is  valu- 
able alike  to  the  surgeon  and  the  physician,  the 
oculist,  the  aurist,  the  gynascologist,  the  alienist, 
and  the  general  practitioner,  for,  unhappily,  the 
subject  of  which  it  treats  exercises  a  defining  influ- 
ence on  a  large  proportion  of  the  ills  of  humanity. 
From  the  foetus  in  utero  to  the  octogenarian  '  the 
trail  of  the  serpent  is  over  them  all,'  and  every 
practitioner  of  medicine  in  every  varying  circum- 
stance of  practice  may  {)n  ifit  by  Dr.  Keyes's  labors." 
— Pittsburgh  JJtdical  Review. 


Specimen  op  Ilu'stratiom. 


KEYES.  The  Tonic  Treatment  of  Syphilis.  By  E.  L.  Keyes, 
A.  M.,  M.  D.,  Adjunct  Professor  of  Surgery  and  Professor  of  Dermatology 
in  the  Bellevue  Hospital  Medical  College,  etc.  8vo.  83  pages.  Cloth, 
$1.00. 

"  My  studies  in  syphilitic  blood  have  yielded  results  at  once  so  gratifying  to  me,  and  so  convincing 
a=;  to  the  tonic  influence  of  minute  doses  of  mercury,  that  I  feel  impelled  to  lay  this  brief  treatise  before 
the  medical  public  in  support  of  a  continuous  treatment  of  syphilis  by  small" (tonic)  doses  of  mercury. 
I  believe  that  a  general  trial  of  the  method  will,  in  the  long  run,  vindicate  its  excellence." — Extract  from 
I'reface. 

KINGSLEY.  A  Treatise  on  Oral  Deformities,  as  a  Branch  of 
Mechanical  Surgery.  By  Norman  W.  Kingsley,  M.  D.  S.,  D.  D.  S., 
President  of  the  Board  of  Censors  of  the  State  of  New  York,  late  Dean 
of  the  New  York  College  of  Dentistry  and  Professor  of  Dental  Art  and 
Mechanism,  etc.,  etc.  With  over  S.'jO  Illustrations.  Svo.  Cloth,  $5.00  ; 
sheep,  16.00. 

"  I  have  read  with  great  pleasure  and  much 
profit  your  valuable  '  Treatise  on  Oral  Deformities.' 
The  work  contains  much  original  matter  of  great 
practical  value,  and  is  full  of  useful  information, 
which  will  be  of  groat  benefit  to  the  profession." — 
Lewis  A.  Sayre,  M.  D.,  LL.  D.,  Professor  of  Or- 
thopedic Svrgerii  and  Clinical  Surgery.^  Bellevue 
Hospital  Medical  College. 

"  A  casual  glance  at  this  work  might  impress 
the  reader  with  the  idea  that  its  contents  were  of 
more  practical  value  to  the  dentist  tlum  to  the  ger- 
eral  practitioner  or  surgeon.  But  it  is  by  no  means 
a  mere  work  on  dentistry,  although  a  practical 
knowledge  of  the  latter  art  seems  to  be  essential  to 
the  carrying  out  of  the  author's  views  regarding 
the  correction  of  the  different  varieties  of  oral  de- 
formities of  which  he  treats.  We  would  be  doing 
injustice  to  the  work  did  not  we  make  particular 
reference  to  the  masterly  chapter  on  tlie  treatment 
of  fractures  of  the  lower  jaw.  The  whole  subject 
is  so  thoroughly  studied  tnat  nothing  is  left  to  be 
desired  by  any  siugeon  who  wishes  to  treat  these 
fractures  intelligently  and  successfully.  The  work, 
as  a  whole,  beai's  marks  of  originality  in  every  sec- 
tion, and  impresses  the  reader  with  the  painstaking 
efforts  of  the  autlior  to  get  at  the  truth,  and  apply 
it  in  an  ingenious  and  practical  w;iy  to  the  want's 
of  the  general  practitioner,  the  surgeon,  and  the 
dentist." — Medical  liecord. 


CATALOGUE  OF  MEDICAL  WORKS. 


29 


"  The  profession  is  to  be  congratulated  on  pos- 
sessing so  valuable  an  addition  to  its  literature,  and 
the  author  to  be  unstintedly  praised  for  his  success- 
ful issue  to  an  arduous  undertaking.  The  work 
bears,  in  a  word,  every  e\'idence  of  having  been 
"written  leisurely  and  with  care.  .  .  ." — Dental 
Cosmos. 

"I  consider  it  to  be  the  most  valuable  work 
that  has  ever  appeared  in  this  country  in  any  de- 
partment of  the  science  of  dental  surgery.  There 
is  no  doubt  of  its  great  value  to  every  man  who 
wishes  to  study  and  "practice  this  branch  of  surgery, 
and  I  hope  it  may  be  adopted  as  a  text-book  in 
every  dental  college,  that  the  students  may  have 
the  benefit  of  the  great  experience  of  the  author. 
It  places  many  things  between  the  covers  of  one 
book  which  heretofore  I  have  been  obliged  to  look 
for  in  many  directions,  and  often  without  success." 
— Feajtk  Abbot,  M.  D.,  Dean  of  the  2s ew  York 
College  of  Dentistry. 

"  The  writer  does  not  hesitate  to  express  his 
"belief  that  the  chapters  on  the  '  esthetics  of  den- 
tistry '  will  be  found  of  more  practical  value  to  the 
prosthetic  dentist  than  all  the  other  essays  on  this 
subject  existent  in  the  English  language.  ...  A 
perusal  of  its  pages  seems  to  compel  the  mind  to 
advance  in  directions  variously  indicated ;  so  vari- 
ously, indeed,  that  there  is  hardly  a  page  of  the 
book  which  does  not  contain  some  important  truth, 
some  pregnant  hint,  or  some  valuable  conclusion." 
— Dental  Miscellany. 


"  I  congratulate  you  on  having  written  a  book 
containing  so  much  valuable  and  original  matter. 
It  will  prove  of  value  not  only  to  dentists,  but  also 
to  surgeons  and  physicians." — Feaitk  HASirs-GS 
IlAini-TON,  M.  D.,  LL'.  D.,  Professor  of  the  Practice 
of  Surgery  with  Operations,  and  of  Clinical  Sur- 
gery in  Belleviie  Hospital  Medical  College, 

SpErniES'  or  Illusteatiok. 


"To  the  surgeon  and  general  practitioner  of 
medicine,  as  well  as  the  dentist,  its  instruction  will 
be  found  invaluable.  It  is  clear  in  style,  practical 
in  its  application,  comprehensive  in' its  illustra- 
tions, ancl  so  exhaustive  that  it  is  not  likely  to  meet 
in  these  i^espects  a  rival." — William  H.  Dwixelle, 
A.M.,  M.D. 


liEGG.     On  the  Bile,   Jaundice,   and  Bilious  Diseases.      By  J. 

WiCKHAM  Legg,  31.  D.,  F.  R.  C.  S.,  Assistant  Physician  to  St.  Bartholo- 
mew's Hospital,  and  Lecturer  on  Pathological  Anatomy  in  the  Medical 
School.  With  Illustrations  in  Chromo-lithography.  8vo.  719  pages. 
Cloth,  $6.00  ;  sheep,  ST. 00. 


"...  And  let  us  turn — which  we  gladlv  do — 
to  the  mine  of  wealth  which  the  volume  itself  con- 
tains, for  it  is  the  outcome  of  a  vast  deal  of  labor; 
so  great,  indeed,  that  one  unfamiliar  with  it  would 
be  surprised  at  the  number  of  facts  and  references 
which  the  book  contains." — Medical  Tirn,es  and 
Gazette,  London. 

"  The  book  is  an  exceedingly  good  one,  and,  in 
some  points,  we  doubt  if  it  could  be  made  better. 
.  .  .  And  we  venture  to  say,  after  an  attentive 
perusal  of  the  whole,  that  any  one  who  takes  it  in 
hand  will  derive  from  it  both  information  and 
i")leasure  ;  it  gives  such  ample  evidence  of  honest 
hard  work,  of  wide  reading,  and  an  impartial  at- 
tempt to  state  the  case  of  jaundice,  as  it  is  known 
by  observation  up  to  the  present  date.  The  book 
w'ill  not  only  live,  but  be  in  the  enjoyment  of  a 
vigorous  existence  lonsr  after  some  of  the  more  pop- 
ular productions  of  the  present  age  are  buried,  past 
all  hope  of  resurrecdon." — 'London  Medical 
Record. 

'•'•  This  portly  tome  contains  the  fullest  account 
-of  the  subjects  of  which  it  treats  in  the  English 
lancritage.  The  historical,  scientific,  and  practical 
details  are  all  equally  well  worked  out,  and  to- 
gether constitute  a  repertorium  of  knowledge 
which  no  practitioner  can  well  do  without.  The 
illustrative  chromo  -  lithographs  are  beyond  all 
praise." — Edinburgh  Medical  Journal. 


"Dr.  Legg's  treatise  is  a  really  great  book,  ex- 
hibiting immense  industry  and  research,  and  full 
of  valuable  information." — American  Journal  of 
Medical  Science. 

"  It  seems  to  us  an  exhaustive  epitome  of  all 
that  is  known  on  the  subject."  —  Philadelphia 
Medical  Tirnes. 

"  This  volume  is  one  which  will  command  pro- 
fessional respect  and  attention.  It  is.  perhaps,  the 
most  comprehensive  and  exhaustive  treatise  upon 
the  subject  treated  ever  published  in  the  English 
language." — Maryland  Medical  Journal. 

"It  is  the  work  of  one  who  has  thoroughly 
studied  the  subject,  and  who,  when  he  finds  the 
evidence  conflicting  on  disputed  points,  has  at- 
tempted to  solve  the  problem  by  experiments  and 
observations  of  his  own." — Praciitioner,  London. 

"  It  is  a  valuable  work  of  reference  and  a 
welcome  addition  to  medical  literature." — Dublin 
Journal  of  Medical  Science. 

"...  The  reader  is  at  once  struck  with  the 
immense  amount  of  research  exhibited,  the  author 
having  left  unimproved  no  accessible  source  of  in- 
formation connected  with  his  subject.  It  is,  in- 
deed, a  valuable  book,  and  the  best  storehouse  of 
knowledge  in  its  department  that  we  know  of." — 
Pacific  Medical  and  Surgical  Journal. 


30 


D.  APPLETON  &    CO:S  ILLUSTRATED 


LETTERMAN.      Medical   Recollections   of  the   Army   of  the 

Potomac.     By  Jonathan  Letterman,  M.  D.,  late  Surgeon  U.  S.  A.,  and 

Medical   Director  of   the  Army  of    the   Potomac.       8vo.       194   pages. 

Cloth,  $1.00. 

"•  We  venture  to  assert  that  but  few  who  open  this  vol  nine  of  medical  annals,  pregnant  as  they  are 
with  instruction,  will  care  to  do  otherwise  than  finish  them  at  a  .sitting." — Mtdical  Record, 

LITTLE.  Medical  and  Surgical  Aspects  of  In-Knee  (Genu-Val- 
gum)  :  Its  Relation  to  Rickets  ;  its  Prevention  ;  and  its  Treatment,  with 
or  without  Surgical  Operation.  By  W.  J.  Little,  M.  D.,  F.  R.  C.  P.,  late 
Senior  Physician  to  and  Lecturer  on  Medicine  at  the  Loi)don  Hospital  \ 
Visiting  Physician  to  the  Infant  Orphan  Asylum  at  Wanstead  ;  the  Earls- 
wood  Asylum  for  Idiots  ;  Founder  of  the  Royal  Orthopaedic  Hospital,  etc. 
Assisted  by  E.  Muirhead  Little,  M.  R.  C.  S.  With  complete  Index,, 
and  illustrated  by  upward  of  50  Figures  and  Diagrams.  8vo.  161  pages. 
Cloth,  $2.00. 


LORING.  A  Text-Book  of  Ophthalmoscopy.  By  Edw  ard  G.  Lob- 
iNG,  M.  D.  Part  I. — The  Normal  Eye,  Determination  of  Refraction,  and 
Diseases  of  the  Media.  With  131  Illustrations,  and  Four  Chromo-Litho- 
graph  Plates,  containing  14  Figures.      8vo.      267  pages.     Cloth,  15.00. 

Part  II. — Edited  by  F.  B.  Loring,  M.  D.  Diseases  of  the  Retina,  Optic 
Nerve,  and  Choroid  :  Their  Varieties  and  Complications,  8vo.  With  Il- 
lustrations and  Chromo-Lithographic  Plates.     Cloth,  $5.00. 


Specimen  of  Ii.libtration. 


"In  tl)is  book  Dr.  Lorin^  has  <;iven  u.s  a  suVi- 
stantial  exposition  ot  Nature's  deeds  and  misdeeds 
as  they  are  found  written  in  the  eye,  and  the  key  by 
means  of  whicli  they  can  be  compi'ehended." — W  . 
K.  Amick,  A.m.,  M.D.,  Prof,  of  Ophthalmology  and 
Otology^  Cincinnati  Colltge  of  Med.  and  Surgery. 


"  Dr.  E.  G.  Loring  has  written 
a  very  valuable  book,  and  one 
\\  hich  every  physician  who  uses, 
or  wishes  to  use,  the  ophthalmo- 
scope should  possess.  .  .  .  The 
hook  had  a  master  of  its  scientific 
principles  for  its  author,  and  a 
master  of  the  book-maker's  art  for 
its  publisher.  So  far  as  we  know, 
it  has,  in  this  branch  of  ophthal- 
mic science,  no  equal  in  the  Eng- 
lish language." — North  Carolina 
Medical  Journal. 

"  Although  American  ophthal- 
mologists' have  done  much  good 
work,  and  as  expert  operators  are 
excelled  by  none,  we  have  no  work 
which  can  take  rank  as  a  text-book 
with  many  English,  German,  and 
French  books.  It  takes  but  a  brief 
examination  of  this  work  to  dem- 
onstrate its  superiority  to  many 
of  the  so-called  text  -  books  on 
ophthalmoscopy  which  have  ap- 
peared during  'the  past  few  years. 
The  chapter  devoted  to  directions 
for  using  the  ophthalmoscope  can 
not  be  excelled,  and  every  student 
should  be  as  familiar  with  it  as 
with  Grav's  anatomy.  The  chapter  devoted  to  the 
fundus  of  the  eye  is' unusually  full,  and  the  portion 
devoted  to  '  anomalies'  can  not  fail  to  be  of  interest 
even  to  the  specialist.  The  lithographs  are  very 
good,  manv  of  them  new  to  ophthalmic  text- 
books."—  Cleveland  Medical  Gazette. 


CATALOGUE  OF  MEDICAL  WORKS. 


31 


Specijieks  of  Lllusteations. 


LiUSK.  The  Science  and  Art  of  Midwifery.  By  William  Thomp- 
so:!^  LusK,  M.  A.,  M.  D.,  Professor  of  Obstetrics  and  Diseases  of  Women 
aud  Children  in  the  Bellevue  Hospital  Medical  College  ;  Obstetric  Surgeon 
to  the  Maternity  and  Emergency  Hospitals  ;  and  Gynaecologist  to  the 
Bellevue  Hospital.  New  edition,  revised  and  enlarged.  With  246  Illus- 
trations.    8vo.     Cloth,  $5.00  ;  sheep,  16.00. 

"  It  is  but  a  short  time  since  we  had 
occasion  to  review  this  work,  of  which  we 
were  enabled  to  speak  in  the  highest  tenns 
of  praise.  The  rapid  advance  of  many  de- 
partments of  obstetrics  has  meautiine  called 
for  a  few  additions.  These  having  been 
made,  it  can  be  confidently  said  that 
Lusk's  midwifery  holds  a  high  place 
amongst  American  authors,  and  deserves 
to  be'extensively  employed  for  reference, 
and  recommended  to  students  as  a  relia- 
ble and  unusually  readable  text-book." — 
Canada  Medical  and  ISurgical  Journal. 

"  The  book  is  now  beyond  criticism, 
for  it  has  been  accepted  by  the  unerring 
judgment  of  the  great  body  of  physicians. 
We  congratulate  Dr.  Lusk  upon  this  reward 
for  the  immense  labor  he  has  bestowed 
upon  it." — Kew  York  Medical  Journal. 

"  It  contains  one  of  the  best  expositions 
of  the  obstetric  science  and  practice  of 
the  diiy  with  which  we  are  acquainted. 
Throughout  the  work  the  author  shows  an 
intimate  acquaintance  with  the  literature 
of  obstetrics,  and  gives  evidence  of  large 
practical  experience,  great  discrimination, 
and  sound  judgment.  We  heartily  recom- 
mend the  book  as  a  full  and  clear  exposi- 
tion of  obstetric  science  and  safe  guide  to 
to  student  and  practitioner." — London 
Lancet. 

"  The  work  is,  perhaps,  better  adapted 
to  the  wants  of  the  student  as  a  text- 
book, and  to  the  practitioner  as  a  work 
of  reference,  than  any  other  one  publi- 
cation on  the  subiect.  It  contains  about 
all  that  is  known  of  the  ars  obstetrica^ 
and  must  add  greatly  to  both  the  fame 
and  fortune  of  the  distinguished  au- 
tbor." — Medical  Herald,  Louisville. 

"Dr.  Lusk's  style  is  clear,  generally 
concise,  and  he  has  succeeded  in  putting 
in  less  than  seven  hundred  pages  the 
'lest  exposition  in  the  English  language 
"  obstetric  science  and  art.     The  book 
will  prove  invaluable 
alike  to  the  student 
and  the  practitioner. " 
—  American  Practi- 
tioner. 

"Dr.  Lusk's  book 
is  eminently  viable. 
It  can  not  faU  to  live 
and  obtain  the  honor 
of  a  second,  a  third, 
aud  nobody  can  fore- 
tell how  many  edi- 
tions. It  is  the  mature 
product  of  great  in- 
dustry and  acute  ob- 
servation. It  is  by  far 
the  most  leai'ned  and 
most  complete  expo- 
sition of  the  science 
and  art  of  obstetrics  written  in  the  English  language.  It  is  a  book  so  rich  in  scientific  and  practical  in- 
formation that  nobody  practicing  obstetrics  ought  to  deprive  himself  of  the  advantage  he  is  sure  to  gain 
from  a  frequent  recourse  to  its  pages." — American  Journal  of  Obstetrics. 


32  />.  APPLET  ON  &    CO:S  TLLUSTRATED 


IjITYS.  The  Brain  and  its  Functions.  By  J.  Luys,  Physician  to  the 
Hospice  de  la  Salpetriere.     With  Illustrations.     12mo.     Cloth,  $1.50. 

"  No  livin?  physiolocrist  is   better  entitled  to  ing  and  valuable  are  the  chapters  dealing:  with  the 

ppeak  with  authority  upon  the  structure  and  tunc-  genesis   and   evolution  of  memory,  the  develop- 

tions  of  the  brain  than  Dr.  Luys.     His  studies  on  ment  of  automatic  activity,  and  the  development 

tlie  anatomy  of  the  nervous  system  are  acknowl-  of  the  notion  of  personality." — Boston  Evening 

edired  to  be  the  fullest  and  most  svstematic  ever  Trarelhr. 

undertaken.  "-^Y.  Jamess  Gazette.  "  ,,  ^^  ^^^_^^  ,^^  ^,^^  ^^^^  ^^  ^^^  ^^,^^^  ^^^^^^^  j^_ 

"  It  is  not  too  much  to  say  that  M.  Luys  has  sane  Asvlum,  is  one  of  the  most  eminent  and  suc- 

2one  further  than  any  other  investigator  into  this  cessful  investigators  of  cerebral  science  now  liv- 

gre;it  field  of  study^  and  only  those  who  are  at  ing ;  and  he  has  given  unque>tionably  the  clearest 

least  dimly  aware  of  the  vasi  changes  going  on  in  and  most  interesting  brief  account  yet  made  of  the 

the  realm"  of  psychology  can  appreciate   the   im-  structure  and  operations  of  the  brain." — Popular 

portance  of  his  revelations.     Particularly  interest-  iScience  MontTihi. 

MAE.KOE.  A  Treatise  on  Diseases  of  the  Bones.  By  Thomas 
M.  Markoe,  M.  D.,  Professor  of  Surgery  in  the  College  of  Physicians  and 
Surgeons,  New  York,  etc.  With  numerous  Illustrations.  8vo.  416  pages. 
Cloth,  84.50. 

This  valuable  work  is  a  treatise  on  Diseases  of  the  Bones,  embracing  their  structural  changes  as 
affected  by  disease,  their  clinical  historv  and  treatment,  including  also  an  account  of  the  various  tumors 
which  crrow  in  or  upon  them.  None  ot'  the  irijurUs  of  bone  are  included  in  its  scope,  and  no  joint  dis- 
eases, excepting  where  the  condition  of  the  bone  is  a  prime  factor  in  the  problem  of  disease.  As  the 
work  of  an  eminent  surgeon  of  large  and  varied  experience,  it  may  be  regarded  as  the  best  on  the  sub- 
ject, and  a  valuable  contribution  to  medical  literature. 

MAXJDSLEY.  Body  and  Mind  :  An  Inquiry  into  their  Connection 
and  Mutual  Influence,  especially  in  reference  to  Mental  Disorders  ;  an  en- 
larged and  revised  edition,  to  which  are  added  Psychological  Essays.  By 
Hesky  Maudsley,  M.  D.,  London.     12mo.     275  pages.     Cloth,  $1.50. 

The  general  plan  of  this  work  may  be  described  as  being  to  bring  man,  both  in  his  physical  and 
mental  relations,  as  much  as  possible  within  the  scope  of  scientific  inquiry. 

"  Many  and  valuable  books  have  been  written  vatious  beyond  a  smattering  of  dogmatic  psychol- 

by  English  physicians  on  insanity,  idiocy,  and  all  ogy  learned  at  college.    To  effect  a  reconciliation 

tl'ie  forms  of  mental  aberration.    But  derangement  between  the  Psychology  and  the  Pathology  of  the 

had  always  been  treated  as  a  distinct  subject,  and  mind,  or  rather  to  construct  a  basis  for  both  in  a 

therefore'  empirically.      Thaf  the  phenomena  of  common  science,   is   the   aim  of  Dr.  Maudsley's 

sound  and  unsound  minds  are  not  matters  of  dis-  book." — London  Saturday  Review. 
tinct  investigation,  but  inseparable  parts  of  one 

and  the  same  inquiry,  seems  a  truism  as  soon  as  "  A  representative  work,  which  every  one 
stated.  But,  strange  to  say,  they  had  always  been  must  study  who  desires  to  know  what  is  do- 
pursued  separately  and  been  in  the  hands  of  two  ing  in  the  way  of  real  progress,  and  not  mere 
distinct  classes  of  investigators.  The  logicians  chatter,  about  mental  physiology  and  pathology." 
and  metaphysicians  occasionally  borrowed  a  stray  — Lancet. 
fact  from  the   abundant   cases  compiled   by   the 

medical   authorities ;    buu  the   physician,   on  the  "  It  distinctly  marks  a   step  in  the  progress 

other  hand,  had  no  theoretical  clew  to  his  obser-  of  scientific  psychology." — 'Ihe  Practitioner. 

MAXJDSLEY.  Responsibility  in  Mental  Diseases.  By  Henry 
Maudsley,  M  D.,  London.     12mo.     313  pages.     Cloth,  81.50. 

"  This  book  is  a  compact  presentation  of  those  all   phases  of  social  relation,  in  which  obligation 

facts   and   principles  which   require   to    be   taken  enters    as    an    element.      The   work    is    new    in 

into  account   in   estimating  human  responsibility  plan,    and    was    written    to    supply    a    wide-felt 

— not  legal  responsibility   merely,  but  responsi-  want   which   has   not  hitherto   been   met." — The 

bility   for  conduct  in  the  family",  the  school,  and  Popular  Science  Monthly. 

MAUDSLEY.  The  Pathology  of  Mind.  Being  the  third  edition  of 
the  Second  Part  of  the  "  Physiology  and  Pathology  of  Mind,"  recast,  en> 
larged,  and  rewritten.  By  Henry  Maudsley,  M.  D.,  London.  12rao. 
580  pages.     82.00. 

coy  TESTS. — Chapter  I.  Sleeping  and  Dreaming;  IL  Hypnotism,  Somnambulism,  and  Allied 
States  ;   in.  The  Causation  and  Prevention  of  Insanity  :    (A;  Etiological;   TV.  The  same  continued ; 


CATALOGUE  OF  MEDICAL   WORKS. 


33 


V.  The  Causation  and  Prevention  of  Insanity :  (B)  Pathological;  VI.  The  Insanity  of  Early  Life  • 
VII.  The  Symptomatology  of  Insanity  ;  VIIL  The  same  continued  ;  IX.  Clinical  Groups  of  Mental 
Disease  ;  X.  Tne  Morbid  Anatomy  of  Mental  Derangement ;  XI.  The  Treatment  of  Mental  Disorders. 

The  new  material  includes  chapters  on  "Dreaming,"  "Somnambulism  and  its  Allied  States,"  and 
ge  additions  in  the  chapters  on  the  "  Causation  and  Prevention  of  Insanity." 


lar; 

"  Unquestionably  one  of  the  ablest  and  most 
important  works  on  the  subject  of  which  it  treats 
that  has  ever  appeared,  and  does  credit  to  his 
philosophical  acumen  and  accurate  observation." — 
Medical  Record. 


"Dr.  Maudsley  has  had  the  courage  to  under- 
tate,  and  the  skill  to  execute,  what  is,  at  least  in 
English,  an  original  enterprise."— Zom6?o«  Satur- 
day Review. 


MAUDSLEY.  The  Physiology  of  the  Mind.  Being  the  First  Part 
of  a  tbird  edition,  revised,  enlarged,  and  in  a  great  part  rewritten,  of  "  Tbe 
Physiology  and  Pathology  of  the  Mind."  By  Henet  Mattdslet,  M.  D., 
London.     12mo.     547  pages.     Cloth,  $2.00. 

CONTENTS.— Cha-'^ter  I.  On  the  Method  of  the  Study  of  the  Mind ;  II.  The  Mind  and  the  Ner- 
vous System  ;  III.  The  Spinal  Cord,  or  Tertiary  Nervous" Centers  ;  or.  Nervous  Centers  of  Keflex  Ac- 
tion ;  IV.  Secondary  Nervous  Centers,  or  Sensory  Ganglia  ;  Sensorium  Commune  ;  V.  Hemispherical 
Ganglia  ;  Cortical  Cells  of  the  Cerebral  Hemispheres ;  "ideational  Nervous  Centers  ;  Primary  Nervous 
Centers;  Intellectorium  Commune  ;  VI.  The  Emotions  ;  VII  Volition;  VIII .  Motor  Nervous  Centers, 
or  Motorium  Commune  and  Actuation  or  Effection;  IX.  Memory  and  Imagination. 

'•  The  '  Physiology  of  the  Mind,'  by  Dr.  Mauds-  riched  by  an  instructive  display  of  notes  and  quo- 
ley,  is  a  very  engaging  volume  to  read,  as  it  is  a  tations  from  authoritative  writers  upon  physiology 
fresli  and  vigorous  statement  of  the  doctrines  of  a  and  psychology ;  and  by  illustrative  cases,  which 
s^rowing  scientific  school  on  a  subject  of  transcen-  add  materially  to  the  interest  of  the  book." — Popu- 
(ient  moment,  and,  besides  many  new  facts  and  lar  Science  Jilordhly. 
important  views  brought  out  in  the  text,  is  en- 


McSHERRY.  Health,  and  How  to  Promote  it.  By  Richard 
McSherry,  M.  D.,  Professor  of  Practice  of  Medicine,  University  of 
Maryland  ;  President  of  Baltimore  Academy  of  Medicine,  etc.  12mo. 
18.5  pages.     Cloth,  $1.25. 

"  This  is  a  racy  little  book  of  185  pages,  full  of 
good  advice  and  important  suggestions,  and  writ- 
ten in  a  free  and  easy  style,  which  crops  out  in 
continued  humor  and  crispness  by  which  the  ad- 
vice is  seasoned,  and  which  render  the  reading  of 
the  book  a  pleasant  pastime  to  all,  whether  profes- 
sionals or  non-professionals." — Canadian  Journal 
of  Medical  Science. 


"An  admirable  production  which  should  find 
its  way  into  every  family  in  the  country.  It  com- 
prises" a  vast  amount  of  the  most  valuable  matter 
expressed  in  clear  and  terse  language,  and  the  sub- 
jects of  which  it  treats  are  of  the  deepest  interest 
to  every  human  beino-." — Prof.  S.  1).  Gross,  of 
Jefferson  Medical  College^  Philadelphia. 

"  On  the  whole,  this  little  book  seems  to  us  very 
well  adapted  to  its  purpose,  and  will,  we  hope,  have 
a  wide  circulation,  when  it  can  not  fail  to  do  much 
good." — American  Journal  of  the  Medical  Sciences. 


"It  contains  a  great  deal  of  useful  informa- 
tion, stated  in  a  very  simple  and  attractive  way." 
— Baltimore  Gazette. 


MILLS.    A  Text-Book  of  Comparative  Physiology. 

and  Practitioners  of  Veterinary  Medicine.     Cloth,  $3.00. 


For  Students 


MILLS.  A  Text-Book  of  Animal  Physiology.  With  Introductory 
Chapters  on  General  Biology  and  a  Full  Treatment  of  Reproduction,  for 
Students  of  Human  and  Comparative  Medicine.  By  Wesley  Mills, 
M.  A.,  M.  D,,  Professor  of  Physiology  in  McGill  University  and  the  Vet- 


erinary College,  Montreal, 
sheep,  $6.00. 


8vo.     With  505  Illustrations.     Cloth,  $5.00 


"  I  am  delighted  with  Di-.  Mills's  book,  the  plan 
of  which  is  excellent,  and  the  details  well  worked 
out.  It  will  give  students  in  human  physiology  a 
new  insight  into  the  relations  of  the  subject." — 
William'Osler,  M.  D.,  Professor  of  Physiology  in 
Johns  Hopkins  University. 

3 


"...  It  fills  a  gap  in  the  works  on  physi- 
ology hitherto  vacant,  and  I. commend  it  cor- 
dially as  an  excellent  work." — Egbert  Eetburw, 
M.  D.,  Professor  of  Physiology  in  the  Medical 
Department  of  Howard  University,  Washington. 
D.  C. 


34 


Z>.  APPLETON  &    CO:S  ILLUSTRATED 


NEUMANN.  Hand-Book  of  Skin  Diseases.  By  Dr.  Isidor  Neu- 
mann, Lecturer  on  Skin  Diseases  in  the  Royal  University  of  Vienna. 
Translated  from  the  German,  second  edition,  with  Notes,  by  Lucius  D. 
BuLKLEY,  A.  31.,  M.  D.,  Surgeon  to  the  New  York  Dispensary,  Depart- 
ment of  Venereal  and  Skin  Diseases  ;  Assistant  to  the  Skin  Clinic  of  the 
College  of  Physicians  and  Surgeons,  New  York,  etc.,  etc.  8vo.  467  pages 
and  66  \Voodcuts.     Cloth,  §4.00  ;  sheep,  85.00. 

Prof.  Neumann  ranks  second  only  to  Hebra,  whose  assistant  he  was  for  many  years,  and  his  work 
may  be  considered  as  a  fair  exponent  of  the  German  practice  of  Dermatology.  The  Dook  is  abundantly 
illustrated  with  plates  of  the  liistolosy  and  pathology  of  the  skm.  The  translator  has  endeavored,  by 
means  of  notes  from  French,  English,  and  American  sources,  to  make  the  work  valuable  to  the  student 
as  well  as  to  the  practitioner. 


"  It  is  a  work  which  I  shall  heartily  recommend 
to  my  class  of  students  at  theUniversity  of  Pennsyl- 
vania, and  one  which  I  feel  sure  will  do  much  to- 
ward enlightening  the  profession  on  this  sub- 
ject."— Louis  A.  Duhrixg. 

"  There  certainly  is  no  work  extant  wliich  deals 
so  thoroughly  with'  the  Pathological  Anatomy  of 
the  Skin  as"  does  this  hand-book." — JS'ew  Tork 
Medical  Eecord. 


"  I  have  already  tv,'ice  expressed  my  favorable 
opinion  of  the  book  in  print,  and  am  glad  that  it  is 
given  to  the  public  at  last." — James  C.  White, 
Boston. 

''  More  than  two  years  ago  we  noticed  Dr. 
Neumann's  admirable  work  in  its  original  shape, 
and  we  are  therefore  absolved  from  the  necessity  of 
saying  more  than  to  repeat  our  strong  recommenda- 
tion of  it  to  English  readers." — Practitioner. 


NIEMEYER.  A  Text-Book  of  Practical  Medicine.  With  Par- 
ticular Reference  to  Physiology  and  Pathological  Anatomy.  By  the  late 
Dr.  Felix  von  Niemeyer,  Professor  of  Pathology  and  Therapeutics  ; 
Director  of  the  Medical  Clinic  of  the  University  of  Tubingen.  Trans- 
lated from  the  eighth  German  edition,  by  special  permission  of  the  author, 
by  George  H.  Humphreys,  M.  D.,  one  of  the  Physicians  to  Trinity 
Lifirraary,  Fellow  of  the  New  York  Academy  of  Medicine,  etc.,  and 
Charles  E,  ILvckley,  M.  D.,  one  of  the  Physicians  to  the  New  York 
Hospital  and  Trinity  Infirmary,  etc.  Revised  edition  of  1880.  8vo. 
1,628  pages.     Cloth,  $9.00  ;  sheep,  $11.00. 

The  author  undertakes,  first,  to  give  a  picture  of  disease  which  shall  be  as  life-like  and  faithful  to 
nature  as  possible,  instead  of  being  a  mere  theoretical  scheme  ;  secondly,  so  to  utilize  the  more  recent 
advances  of  pathological  anatomy,  physiology,  and  physiological  chemistry,  us  to  furnish  a  clearer  in- 
sight into  the  various  processes  of  disease. 

The  work  has  met  with  the  most  flattering  reception  and  deserves  success ;  has  been  adopted  as  a 
text-book  in  many  of  the  medical  colleges  both  in  this  country  and  in  Europe  ;  and  has  received  the 
very  highest  encomiums  from  the  medical  and  secular  press. 


"  This  new  American  edition  of  Niemeyer  fully 
sustains  the  reputation  of  previou-;  ones,  and  may 
be  considered,  as  to  style  and  matter,  superior  to 
any  translation  that  could  have  been  made  from 
the  latest  German  edition.  It  will  be  recollected 
that  since  the  death  of  Prof.  Niemeyer,  in  1871,  his 
work  has  been  edited  by  Dr.  Eugene  Seitz.  Al- 
though the  latter  gentleman  has  made  manv  addi- 
tions and  changes,  he  lias  destroyed  somewliat  the 
individuality  of  the  original.  The  American  edi- 
tors have  wisely  resolved  to  preserve  the  style  of 
the  author,  and  adhere,  as  closely  as  possible,  to 
his  individual  views  and  his  particular  style.  Ex- 
tra articles  have  been  inserted  on  chronic  alcohol- 
ism, morphia-poisoning,  paralysis  agitans,  sclero- 
derma, elephantiasis,  progressive  pernicious 
anaemia,  and  a  cliapter  on  yellow  fever.  The  work 
is  well  printed  as  usual."— J/<?(//(rtZ  Record. 

"  The  first  inquiry  in  this  country  regarding  a 
German  book  generally  is,  '  Is  it  a  work  of  practi- 
cal value?'  Without  stopping  to  consider  the 
justness  of  the  American  idea  of  tlie  'practical,' 


we  can  unhesitatingly  answer,  'It  is ! '  " — J^eio 
York  Medical  Journal. 

"  It  is  comprehensive  and  concise,  and  is  char- 
acterized by  clearness  and  originality." — Dublin 
(Juarterly  Journal  of  Medicine. 

"  Its  author  is  learned  in  medical  literature  ;  he 
has  arranged  his  materials  with  care  and  judg- 
ment, and  has  thought  over  them." — IJie  Lancet. 

"  While,  of  course,  we  can  not  undertake  a  re- 
view of  this  immense  work  of  about  1,600  pages 
in  a  journal  of  the  size  of  ours,  we  may  say  that 
we  have  examined  the  volumes  very  carefully,  as 
to  whether  to  reconmiend  them  to  practitioners  or 
not ;  and  we  are  glad  to  say,  after  a  careful  review, 
'Buy  the  book.'  The  chapters  are  succinctly 
written.  Terse  terms  and,  in  the  main,  brief 
sentences  are  used.  Personal  experience  is  re- 
corded, with  a  proper  statement  of  facts  and  obser- 
vations by  other  authors  who  are  to  be  trusted.  A 
verv  excellent  index  is  added  to  the  second  volume, 
which  helps  very  much  for  ready  reference." — 
Virginia  Medical  Moiithhj. 


CATALOGUE  OF  MEDICAL   WORKS. 


35 


NIGHTINGALE.     Notes  on  Nursing  :   What  it  is,  axd  what  it  is 
isroT.     By  Florence  Nightitstgale.     12mo.     140  pages.     Cloth,  75  cents. 

These  notes  are  meant  to  give  hints  for  thought  to  those  who  have  personal  charge  of  the  health  of 
others. 

Every-day  sanitary  knowledge,  or  the  knowledge  of  nursing,  or,  in  other  words,  of  how  to  put  the 
constitution  in  such  a  state  as  that  it  will  have  no  disease  or  that  it  can  recover  from  disease,  is  recog- 
nized as  the  knowledge  which  every  one  ought  to  have — distinct  from  medical  knowledge,  which  onTy 
a  profession  can  have. 


OSWALD.    Physical  Education ;  or,  The  Health  Laws  of  Na- 
ture.    By  Felix  L.  Oswald,  M.D.     12nio.     Cloth,  11.00. 


"Dr.  Oswald  is  a  medical  man  of  thorough 
preparation  and  large  professional  experience,  and 
an  extensively  traveled  student  of  nature  and  of 
men.  While  in  charge  of  a  military  hospital  at 
Vera  Cruz,  his  own  health  broke  down  from  long 
exposure  in  a  malarial  region,  and  he  then  struck 
for  the  Mexican  mountains,  where  he  became  di- 
rector of  another  medical  establishment.  He  has 
also  .iourneyed  extensively  in  Europe,  South 
America,  and  the  United  States,  and  always  as  an 
open-eyed,  absorbed  observer  of  nature  and  of 
men.  The  '  Physical  Education '  is  one  of  the 
most  wholesome  and  valuable  books  that  have 
emanated  from  the  American  press  in  many  a  day. 
Not  only  can  everybody  understand  it,  and,  what 
is  more, /eel  it,  but  ever  body  that  gets  it  will  be 
certain  to  read  and  re-read  it.  We  have  known  of 
the  positive  and  most  salutary  iutlueuce  of  the 
papers  as  they  appeared  in  the  '  Monthly,'  and  the 
extensive  demand  for  their  publication  in  a  separate 
form  shows  how  they  have  been  appreciated.  Let 
those  who  are  able  and  wish  to  do  good  buy  it 
wholesale  and  give  it  to  those  less  able  to  obtain 
it." — The  Popular  Science  Monthly. 

"  Here  we  have  an  intelligent  and  sensible  treat- 
ment of  a  subject  of  great  importance,  viz.,  physi- 
cal education.  We  give  the  headings  of  some  of 
the  chapters,  viz. :  Diet ;  In-door  Life  ;  Out-door 
Life;  Gymnastics:  Clothing;  Sleep;  Eecreation ; 
Eemedial  Education  ;  Hygienic  Precautions  ;  Pop- 
ular Fallacies.  These  topics  are  discussed  in  a 
plain,  common-sense  style  suited  to  the  popular 


mind.      Books  of  this  character  can   not  be   too 
widely  read." — Albany  (iV.  Y.')  Argus. 

"Dr.  Oswald  is  as  epigrammatic  as  Emerson, 
as  spicy  as  Montaigne,  and  as  caustic  as  Heine. 
And  yet  he  is  a  pronounced  vegetarian.  His  first 
chapter  is  devoted  to  a  consideration  of  the  diet 
suitable  for  human  beings  and  intants.  In  the 
next  two  he  contrasts  life  in  and  out  of  doors.  He 
then  gives  his  ideas  on  the  subjects  of  gymnastics, 
clothing,  sleep,  and  recreation.  He  suggests  a  sys- 
tem of  remedial  education  and  hygienic  pre- 
cautions, and  he  closes  with  a  diatribe  against 
popular  fallacies." — Philadelphia  Press. 

"  It  is  a  good  sign  that  books  on  physical  train- 
ing multiply  in  this  age  of  mental  straining.  Dr. 
Felix  L.  Oswald,  author  of  the  above  book,  may 
be  somewhat  sweeping  in  his  statements  and  be- 
liefs, but  every  writer  who,  like  him,  clamors  for 
simplicity,  naturalness,  and  frugality  in  diet,  for 
fresii  air  and  copious  exercise,  is  a  benefactor.  Let 
the  dyspeptic  and  those  who  are  always  troubling 
themselves  and  their  friends  about  their  manifold 
ailments  take  Dr.  Oswald's  advice  and  look  more 
to  their  aliments  and  their  exercise." — JS'ew  York 
Herald, 

"  One  of  the  best  books  that  can  be  put  in  the 
hands  of  young  men  and  women.  It  is  very  inter- 
esting, full  of  facts  and  wise  suggestions.  It  points 
out  needed  reforms,  and  the  way  we  can  become  a 
strong  and  healthy  people.  It  deserves  a  wide 
circulation. ' '  — Boston  Commonwealth. 


PEASLEE.  Ovarian  Tumors ;  their  Pathology,  Diagnosis,  and 
Treatmext,  with  Reference  especially  to  Ovariotomy.  By  E.  R. 
Peaslee,  M.  D.,  Professor  of  Diseases  of  Women  in  Dartmouth  College; 
formerly  Professor  of  Obstetrics  and  Diseases  of  Women  in  the  New 
York  Medical  College,  etc.  8vo.  551  pages.  Illustrated  with  many 
Woodcuts,  and  a  Steel  Engraving  of  Dr.  E.  McDowell,  the  "Father  of 
Ovariotomy."     Cloth,  15.00  ;  sheep,  $6.00. 

This  valuable  work,  embracing  the  results  of  many  years  of  successful  experience  in  the  department 
of  which  it  treats,  will  prove  most  acceptable  to  the  entire  profession  ;  while  the  high  standing  of  the 
author  and  his  knowledge  of  the  subject  combine  to  make  the  book  the  best  in  the^  language.  Fully 
illustrated,  and  abounding  with  information^  the  result  of  a  prolonged  study  of  the  subject,  the  work 
should  be  in  the  hands  of  every  physician  in  the  country. 

"  We  deem  its  careful  perusal  indispensable  to 
all  who  would  treat  ovarian  tumoi-s  with  a  good 
conscience." — American  Journal  of  Obstetrics. 


"  In  closing  our  review  of  this  work,  we  can  not 
avoid  again  expressing  our  appreciation  of  the 
thorough  study,  the  careful  and  honest  statements, 
and  candid  spirit,  which  characterize  it.  For  the 
use  of  the  student  we  should  give  the  preference 
to  Dr.  Peaslee' s  ivorJc,  not  onhj  from  its  complete- 
ness^ but  from,  its  more  methodical  arrangement.'''' 
— American  Journal  of  the  Medical  Sciences. 


"  It  shows  prodigal  industry,  and  embodies 
within  its  five  hundred  and  odd  pages  pretty  much 
all  that  seems  worth  knowing  on  the  subject  of 
ovarian  diseases." — Philadelphia  Medical  Times. 


36  D.  APPLET  OX  &    00:S  ILLUSTRATED 


PEREIRA.     Dr.  Pereira's  Elements  of  Materia   Medica    and 

Therapeutics.  Abridged  and  adapted  for  the  Use  of  Medical  and 
Pharmaceutical  Practitioners  and  Students,  and  comprising  all  the  Medi- 
cines of  the  British  Pharmacopoeia,  with  such  others  as  are  frequently 
ordered  in  Prescriptions,  or  required  by  the  Physician.  Edited  by 
Robert  Bextley  and  Theophilus  Redwood.  Xew  edition.  Bi-ought 
down  to  1872.     Royal  8vo.     1,093  pages.     Cloth,  §7.00  ;  sheep,  $8.00. 

PEYER.  An  Atlas  of  Clinical  Microscopy.  By  Alexander 
Pever,  M.  D.  Translated  and  edited  by  Alfred  C.  Girard,  M.  D.,  As- 
sistant Surgeon  United  States  Ai'my.  First  American,  from  the  manu- 
script of  the  second  German  edition,  with  Additions.  90  Plates,  with  105 
Illustrations,  Chromo-Lithographs.     Square  8vo.     Cloth,  $6.00. 

"  All  who  are  interested  in  clinical  microscopy  pare  in  point  of  accuracy  of  detail  and  artistic 
will  be  pleased  with  the  desicrn  and  execution  of  effect  with  the  work  under  consideration." — 
tliis  work,  and  will  feci  under  obligation  to  the  au-  Maryland  Medical  Journal. 
thor,  translator,  and  publishers  for  placing  so  valu- 
able a  work  in  their  hands.  The  plates  in  which  "There  is  probably  no  work  in  any  languasre 
are  figured  the  various  urinary  inorganic  deposits  that  will  prove  of  as  much  real  service  to  the  be- 
are  especially  fine,  and  the  various  fonns  of  tube-  ginner  in  microscopy  as  the  one  before  us,  and^  this 
ca-sts,  hvaliiie,  waxy,  epithelial,  and  mucous,  are  value  is  due  to  the  number  and  excellence  of  the 
depicted  with  great  fidelity  and  accuracy." —  plates  with  wliich  it  is  literally  crowded.  One 
Philadelphia  Medical  Times.^  ordinai-y  plate  is  often  worth  ten  pages  of  explana- 
tion ;  who  then  can  reckon  the  assistance  lent  by 

"  To  those  students  and  practitioners  of  medi-  a    life-size,  well-colored  plate   such  as  we    have 

cine  who  are  interested  in  microscopical  work  and  here?" — Peoria  Medical  Monthly. 
who  are  familiar  with  the  use  of  this  valuable  aid 

to  human  vision  in  the  study  of  nature,  the  present  "  This  valuable  and  beautiful  addition  to  scien- 

work  will   prove   of  incalculable   value,  smce   it  tiflc  and  medical  literature  can  not  but  be  destined 

represents  the  original  work  of  an  accomplished  to  receive  a  warm  welcome  from  a  wide  circle  of 

microscopist  and  artist.    Accompanving  the  plates  students   and  practitioners.    ...    So  practically 

is  a  text  of  explanatory  notes  showing  the  various  useful  are  its  contents,  and  so  attractive — one  may 

methods  of  working  with  the  microscope  and  the  almost  say  artistic — is  the  form  in  which  it  is  pre- 

significauce  of  what  is  observed.     The  plates  have  sented,  that  to  see  it  is  to  covet  it ;  to  own  it  is  to 

been   most   handsomely  printed.     We  have  seen  rejoice  in  its  possession." — Xew  England  Medical 

nothing  in  this  special  line  of  study  that  will  com-  Gazette. 

PIFFARD.  A  Practical  Treatise  on  Diseases  of  the  Skin.  By 
Henry  G.  Piffard,  A.  M.,  M.  D.,  Clinical  Professor  of  Dermatology, 
University  of  the  City  of  New  York  ;  Surgeon  in  Charge  of  the  New 
York  Dispensary  for  Diseases  of  the  Skin,  etc.  ;  assisted  by  Robert  M, 
Fuller,  M.  D.,  Lecturer  on  Dermatology,  University  of  the  City  of  New 
York,  etc.  With  Fifty  full-page  Original  Plates  and  Thirty-three  Illus- 
trations in  the  Text.     4to.     To  be  sold  by  subscription  only. 

POMEROY.  The  Diagnosis  and  Treatment  of  Diseases  of  the 
Ear.  By  Oaven  D.  Pomeroy,  M.  D.,  Surgeon  to  the  Manhattan  Eye  and 
Ear  Hospital,  etc.  "With  100  Illustrations.  New  edition,  revised  and  en- 
larged.    8vo.     Cloth,  83.00. 

"  The  several  forms  of  aural  disease  are  dealt  "  This  .second  edition  has  been  carefully  revised, 

with   ill  a  manner  exceedingly  satisfactory.     The  and  a  number  of  pages  as  well  as  some  illustrations 

work  is  quite   exhaustive  in   its   scope,  and  will  have  been  added,  so  as  to  render  the  volume  an  ac- 

represent  an  authority  on  this  subject  which  we  curate  representative  of  the  science  of  aural  surgery 

believe  will   be  duly  appreciated   by  the   profes-  as.  it  ex\s,lAio-<\a\.' '—Medical and Svrgical Reporter. 

sion." — Medical  Record.  .  ^ 

Lvery  country  practitioner  and  those  in  small 

"  The  author  uses  good  language,  telling  in  a  towns— in"  fact,  every  doctor  who  wants  to   treat 

clear  and  interesting  manner  what  he  has  to  say.  ear-diseases— would  "be  better  prepared  by  having 

The  book  is  a  valuable  one  for  both  students  and  read  Dr.  Pomerov's  very  excellent  text-Book."— 

practitioners."— Za»ce«a«<i  Clinic.  DanieVs  Terns  Medical  journal. 


1 


CATALOGUE   OF  MEDICAL   WORKS. 


37 


POORE.  Osteotomy  and  Osteoclasis,  for  the  Correction  of  Deformi- 
ties of  the  Lower  Limbs.  By  Charles  T.  Poore,  M.  D.,  Surgeon  to  St. 
Mary's  Free  Hospital  for  Children,  New  York.  8vo.  202  pages,  with  50 
Illustrations.     Cloth,  $2.50. 

Specimens  of  Illusteations. 


"  Tliis  handsome  and  carefully  prepared  mono- 
graph treats  of  osteotomy  as  applied  to  the  i-epair 
of  genu  valgum,  genu  varum,  anchylosis  of  the 
knee-joint,  deformities  of  the  hip-joint,  and  for 
curves  of  the  tibia.  The  author  has  enjoyed  large 
opportunities  to  study  these  special  malformations 
in  the  hospitals  to  which  he  is  attached,  and  de- 
scribes the  operations  from  an  ample  observation. 
Quite  a  number  of  well-engraved  illustrations  add 
to  the  value  of  the  volume,  and  an  exhaustive  bib- 
liography appended  enables  the  reader  to  pursue 
any  topic  in  which  he  may  be  interested  into  the 
productions  of  other  writers." — Medical  and  Sur- 
gical Reporter. 

"  Dr.  Poore,  who  has  already  become  so  well 
known  by  journal  articles  on  bone  surgery,  has  con- 


densed his  experience  in  the  work  before  us.  He 
has  succeeded  in  doing  this  in  a  very  satisfactory 
way.  We  can  not  too  strongly  commend  the  clear 
and  succinct  manner  in  which  the  author  weighs 
the  indications  for  treatment  in  particular  cases. 
In  so  doing  he  shows  a  knowledge  of  his  subject 
which  is  as  extensive  as  it  is  profound,  and  no  one 
at  all  interested  in  orthopedy  can  read  his  conclu- 
sions without  profit.  His  own  cases,  which  are 
carefully  reported,  are  valuable  additions  to  the  lit- 
erature of  the  subject.  These,  together  with  oth- 
ers, which  are  only  summarized,  contain  so  much 
practical  information  and  sound  surgery  that  they 
give  a  special  value  to  the  work,  altogether  inde- 
pendent of  its  other  excellences.  It  is  a  good  book 
m  every  way,  and  we  congratulate  the  author  ac- 
cordingly."— Medical  Record. 


QiXJAlN.  A  Dictionary  of  Medicine,  including  General  Pathology, 
General  Therapeutics,  Hygiene,  and  the  Diseases  peculiar  to  Women  and 
Children.  By  Various  Writers.  Edited  by  Richard  Quain,  M.  D., 
F.  R.  S.,  Fellow  of  the  Royal  College  of  Physicians  ;  Member  of  the 
Senate  of  the  University  of  London  ;  Member  of  the  General  Council  of 
Medical  Education  and  Registration  ;  Consulting  Physician  to  the  Hos- 
pital for  Consumption  and  Diseases  of  the  Chest  at  Brompton,  etc.  8vo. 
1,834  pages,  and  138  Illustrations.  Half  morocco,  18.00.  Sold  only  by 
subscription. 

This  work  is  primarily  a  Dictionary  of  Medicine,  in  which  the  several  diseases  are  fully  discussed 
in  alphabetical  order.  The  description  of  each  includes  an  account  of  its  setiology  and  anatomical  char- 
acters ;  its  symptoms,  course,  duration,  and  termination  ;  its  diagnosis,  prognosis,  and,  lastly,  its  treat- 
ment.    General  Pathology  comprehends  articles  on  the  origin,  characters,  and  nature  of  disease. 

General  Therapeutics  includes  articles  on  the  several  classes  of  remedies,  their  modes  of  action,  and 
on  the  methods  of  their  use.     The  articles  devoted  to  the  subject  of  Hygiene  treat  of  the  causes  and 

Erevcntion  of  disease,  of  the  agencies  and  laws  affecting  public  health,  of  the  means  of  preserving  the 
ealth  of  the  individual,  of  the  construction  and  management  of  hospitals,  and  of  the  nursing  of  the 
Bick. 

Lastly,  the  diseases  peculiar  to  women  and  children  are  discussed  under  their  respective  headings, 
both  in  aggregate  and  in  detail. 


38 


D.  APPLETON  &   CO:S  ILLUSTRATED 


Amoncr  the  leading  contributors,  whose  names  at  once  strike  the  reader  as  affording  a  guarantee  of 

the  value  of  their  contributions,  are  the  following  : 


Allbutt,  T.  Clifford,  M.  A.,  M.  D. 

Babxes.  Robert,  M.  D. 

Bastiax,  II.  Charlton,  M.  A.,  M.  D. 

BiNZ,  Carl,  M.  D. 

Bristowe.  J.  Ster,  M.  D. 

Brown-Seqcard,  C.  E.,  M.  D..  LL.  D. 

Bruxtox,  T.  Lauder,  M.  D.,  D.  Sc. 

Fayrer,  Sir  JosEfH,  K.C.S.I.,  M.  D.,  LL.  D 

Fox.  Tilbury,  M.  U. 

Galton,  Captain   Douglas,  E.  E.   (retired). 

GoWERS,  W.  R.,  M.  D. 


Wells.  T.  Spencer. 


Greenfield,  W.  S.,  M.  D. 

Jenner,  Sir  William,  Bart.,  K.  C.  B.,  M.  D. 

Lego,  J.  Wickham,  M.  D. 

Nightingale,  Florence. 

Paget,  Sir  James,  Bart. 

Parkes,  Edmund  A.,  AL  D. 

Pavy,  F.  W.,  M.  D. 

Playfair,  W.  S.,  M.  D. 

Simon,  John,  C.  B.,  D.  C.  L. 

Thompson,  Sir  Henry. 

Waters,  A.  T.  H.,  M.  D. 


"  Not  only  is  the  work  a  Dictionary  of  Medicine 
in  its  fullest  sense,  but  it  is  so  encyclopedic  in  its 
scope  that  it  may  be  considered  a  condensed  re- 
view of  the  entire  field  of  practical  medicine. 
Each  subject  is  marked  up  to  date  and  contains  in 
a  nutsliell  the  accumulated  experience  of  the  lead- 
ing medical  men  of  the  day.  As  a  volume  for 
ready  reference  and  careful  study,  it  will  be  found 
of  immense  value  to  the  general  practitioner  and 
student." — Medical  Record. 

"  The  '  Medical  Dictionary '  of  Dr.  Quain  is 
something  more  than  its  title  would  at  first  indi- 
cate. It  might  with  equal  propriety  be  called  an 
encyclopaedia.  The  different  diseases  are  fully 
discussed  in  alphabetical  order.  The  description 
of  each  includes  an  account  of  its  various  attri- 
butes, often  covering  several  pages.  Although  we 
have  possessed  the  book  only  the  short  time  since 
its  publication,  its  loss  would  leave  a  void  we 
would  not  know  how  to  fill." — Boston  Medical 
and  Surgical  Journal. 

"  Although  a  volume  of  over  1,800  pages,  it  is 
truly  a  multum  in  parvo,  and  will  be  found  of 
much  more  practical  utility  than  other  works 
which  might  be  named  extending  over  many  vol- 
umes. The  profession  of  this  country  are  under 
obligations  to  you  for  the  republication  of  the 
work,  and  1  desire  to  congratulate  vou  on  the  ex- 
cellence of  the  illustrations,  togetiier  with  the 
excellent  typographical  execution  in  all  respects." 
— Austin  Flint,  M.  D. 

"  It  is  with  great  pleasure,  indeed,  that  we  an- 
nounce the  publication  in  this  country,  by  the  Ap- 
pletons,  of  this  most  superb  work.  Of  all  the 
medical  works  which  have  been,  and  which  will 


be,  published  this  year,  the  most  conspicuous  one 
as  embodying  learning  and  research — the  eoinniia- 
tion  into  one  great  volume,  as  it  were,  of  the  whole 
science  and  art  of  medicine — is  the  '  Dictionary  of 
Medicine  '  of  Dr.  Quain.  Ziemssen's  '  Practice  of 
Medicine' and  Reynolds's  'System  of  Medicine' 
are  distinguished  works,  forming  compilations,  in 
the  single  department  of  practice,  of  the  labors  of 
many  very  eminent  physicians,  each  one  in  liis 
contributions  presenting  the  results  of  his  own  ob- 
servations and  experiences,  as  well  as  those  of  the 
investigations  of  others.  But  in  the  dictionary  of 
Dr.  Quain  there  are  embraced  not  merely  the 
principles  and  practice  of  medicine  in  the  con- 
tributions by  the  various  writers  of  eminence,  but 
general  patliology,  general  therapeutics,  hygiene, 
diseases  of  women  and  children,  etc." — C'Cncin- 
nati  Medical  JSeivs. 

"  In  this  important  work  the  editor  has  endeav- 
ored to  combine  two  features  or  purposes:  in  th',- 
first  place,  to  offer  a  dictionary  of  the  technical 
words  used  in  medicine  and  the  collateral  sciences, 
and  also  to  present  a  treatise  on  svstematie  medi- 
cine, in  which  the  separate  articles  on  diseases 
should  be  short  monographs  by  eminent  specialists 
in  the  several  branches  of  medical  and  surgical 
science.  Especially  for  the  latter  purpose,  he 
secured  the  aid  of  such  well-known  gentlemen  as 
Charles  Murchison,  John  Rose  Cormack,  Tilbury 
Fox,  Thomas  Hayden,  William  Aitken,  Charlton 
Bastian,  Brown- Sequard,  Sir  William  Jeiiner, 
Erasmus  Wilson,  and  a  host  of  others.  By  their 
aid  he  may  fairly  be  said  to  have  attained  his 
object  of  '  bringing  together  the  latest  and  most 
complete  information,  in  a  form  wliich  would 
allow  of  ready  and  easy  reference.'  " — Medical  and 
Sunjical  Reporter. 


RANNEY.     The  Applied  Anatomy  of  the  Nervous  System, 

being  a  Study  of  this  Portion  of  the  Human  Body  from  a  Standpoint  of 
its  General  Interest  and  Practical  Utility,  designed  for  Use  as  a  Text- 
book and  as  a  Work  of  Reference.  By  Ambrose  L.  Rais^net,  A.  M., 
31.  D.,  Adjunct  Professor  of  Anatomy  and  late  Lecturer  on  the  Diseases 
of  the  Genito-Urinary  Organs  and  on  Minor  Surgery  in  the  Medical  De- 
partment of  the  University  of  the  City  of  New  York,  etc.,  etc.  Second 
edition,  thoroughly  revised.  8vo.  Profusely  illustrated.  Cloth,  $5.00  ; 
sheep,  $6.00. 

"The  many  favorable  reviews  of  the  first  edi-  omy  and  physiolosry  of  the  nervous  system,  and  a 
tion  of  the  work  and  its  general  adoption  as  a  clear  interpretation' of  the  main  tacts  applicable  to 
text-book  has  induced  the  author  to  modify  its  diagnosis,  will  find  in  tliis  book  all  that  he  could 
scope  and  plan,  with  a  view  of  rendering  it  more  wish.  The  book  contains  791  pages,  and  the  typo- 
worthy  of  commendation.  The  student  who  de-  graphical  and  mechanical  execution  is  superb." — • 
sires  a  trustworthy  guide  in  the  study  of  the  auat-  Indiana  Medical  Journal. 


CATALOGUE  OF  MEDICAL  WORKS. 


89 


"  There  are  very  few  works  on  the  above  sub- 
ject, and  none  at  all  comparable  with  the  one  be- 
fore us.  To  be  perfectly  candid,  we  will  say  that 
we  know  of  no  book  as  valuable  to  the  physician, 
in  every  branch  of  the  profession,  as  the  one 
above  nientioned.  Proper  and  successful  practice 
must  of  necessity  depend  upon  a  proper  diagnosis, 
and  it  is  for  this  end  that  Dr.  Eanney  has  written 
this  work.  Based  upon  a  sound  linowledge  of 
anatomy — minute,  general,  and  special — this  excel- 
lent treatise  covers  the  ground  fully.  The  type  is 
large  and  clear,  and  the  illustrations  are  very  ex- 
cellent, both  in  correctness  and  in  artistic  execu- 
tion. The  thorough  manner  in  which  physiological 
functions  are  pointed  out  in  connection  with 
anatomical  teaching,  thus  leading  one  on  to  ap- 
preciate the  pathological  changes  and  manifest.i- 
tions,  is  a  grand  feature  of  the  book.  2so  progressive 
phy.sician  should  be  without  this  very  valuable 
work." — Southern  Clinic. 

"  The  second  edition  of  Dr.  Eanney's  excellent 
work  on  the  applied  anatomy  of  the  nervous  sys- 
tem has  been  almost  entirely  rewritten,  so  that  it 
includes  the  latest  discoveries  in  the  anatomy  and 
physiology  of  the  brain  and  the  nervous  system. 
A  careful' study  of  the  anatomy  and  uses  of  nerve 
structure  is  of  the  utmost  importance  in  the  cor- 
rect diagnosis  of  a  host  of  diseases  about  which, 
without  the  information  obtained  in  a  work  like 
this,  we  should  be  very  much  in  the  dark.  By 
means  of  a  very  full  table  of  contents  the  reader 
can  turn  at  once  to  the  action  of  every  nerve  and 
branch  of  nerve  in  healtli  and  the  disturbance  pro- 
duced by  it  when  diseased." — New  York  Medical 
Times. 

"  This  work  will  be  found  exceedingly  useful 
by  all  who  come  frequently  in  contact  with  those 
suffering  from  disease  of  tlie  nervous  system.  Its 
object  is  to  aid  in  the  anatomical  diagnosis  of  such 
diseases.  It  is  unusually  complete  in  its  treatment 
of  the  subject.  Numerous  diagrams  and  illustra- 
tions have  been  introduced  in  order  to  make  ex- 
planations clear.  The  present,  although  called  a 
new  edition,  is  practically  a  new  book.  It  is  much, 
larger  and  for  the  most  part  newly  written.  If  we 
were  to  make  any  criticism  upon  the  book,  it  would 
be  to  urge  the  author  to  condense  the  subject- 
matter.  So  much  of  the  substance  of  the  work 
deals  with  the  physiology  of  the  nervous  system 
that  the  title  is  somewhat  misleading  as  regards  its 
scope." — Journal  of  the  American  Medical  Asso- 
ciation. 

"  The  book  will  be  a  great  help  to  the  student 
of  neurology,  since  it  sets  to  his  hand  matter  which 
otherwise  could  be  found  only  by  tedious  research 
through  many  volumes,  and  for  the  same  reason 


Specimen  of  Ili-ustration. 


the  practitioner  will  give  it  hearty  welcome."  — 
Amei'ican  Practitioner  and  News. 

"  This  is  without  exception  one  of  the  best 
treatises  on  Applied  Anatomy  of  the  Nervous  Sys- 
tem to  be  found  in  any  language.  It  is  clearly 
written,  the  type  good,  and  the  plates  are  all  that 
could  be  desired.  In  reading  the  ordinary  works 
on  the  Physiology  of  the  Nervous  Sy.stem,  one 
finds  many  contradictions,  and  many  confused 
ideas  naturally  result.  In  this  work  every  part  is, 
so  far  as  possible,  dealt  with  separately,  carefully, 
and  thoroughly  explained  so  as  to  leave  its  teach- 
ings clear  in  the  mind  of  the  student.  We  espe- 
cially recommend  this  treatise,  for  it  is  a  %york  of 
great  excellence,  and  we  are  sure  one  which  the 
neurologist  will  find  indispensable,  while  the 
generarpractitioner  will  find  it  one  of  the  most 
useful  works  in  his  library." — Canada  Lancet. 


RICHARDSON'.  A  Ministry  of  Health  and  other  Addresses. 
By  B.  W.  RiCHAEDSOx,  M.  D.,  M.  A.,  F;  R  S.,  etc.  12rao.  354  pages. 
Cloth,  11.50. 


*''The  author  is  so  widely  and  favorably  known 
that  any  book  which  bears  his  name  will  receive 
resp^ictful  attention.  He  is  one  of  those  highly 
educated  yet  practical,  public-spirited  gentlemen 
who  adorn  the  profession  of  medicine  and  do  far 
more  than  their  share  towai'd  elevating  its  position 
before  the  public.  This  book,  owing  to  the  char- 
acter of  the  matter  considered  and  the  author's 
att;ractive  style,  affords  means  for  relaxation  and 
instruction  to  every  thoughtful  person." — Medical 
Gazette. 

"  This  book  is  made  up  of  a  number  of  ad- 
dresses on  sanitary  subjects,  which  Dr.  Eichardson 


delivered  at  various  times  in  Great  Britain,  and 
which  are  intended  to  invite  attention  to  the  press- 
ins  reforms  that  are  making  progress  in  medical 
science.  The  work,  which  has  the  great  merit  ot 
being  written  in  the  simplest  and  clearest  language, 
gives  special  attention  to  the  origin  and  causes  ol 
diseases,  and  a  demonstration  of  the  physical  laws 
bv  which  they  may  be  prevented.  .  .  .  The  author 
does  not,  like  some  membere  of  his  profession,  en- 
ter into  a  learned  description  of  cures,  but  traces 
the  causes  of  diseases  with  philosophical  precision. 
The  book  contains  what  every  one  should  know, 
and  members  of  the  medical'  profession  will  not 
find  a  study  of  it  in  vain."— PAife.  Enquirer. 


40 


D.  APPLETON  &    CO:S  ILLUSTRATED 


RICHARDSON.     Diseases  of  Modern  Liife.     By   B.  W.  Richard- 
son, M.  D.,  M.  A.,  F.  R.  S.,  etc.,  etc.     12mo.     520  pages.     Cloth,  S2.00. 


"  In  this  valuable  and  deeply  iuteresting  work 
Dr.  Eichardson  treats  the  nervous  system  as  tlie 
very  principle  of  lite,  and  he  shows  how  men  do  it 
violence,  yet  expect  immunity  where  the  natural 
sentence  is  death." — Charl^thn  Courier. 

"  The  work  is  of  great  value  as  a  practical  guide 
to  enable  the  reader  to  detect  and  avoid  various 
sources  of  disease,  and  it  contains,  in  addition, 
several  introductory  chapters  on  natural  life  and 
natural  death,  the  phenomena  of  disease,  disease 
antecedent   to   birth,   and  on   the   effects   of   the 


seasons  of  atmospheric  temperature,  of  atmospheric 
pressure,  of  inoi^^ture,  winds,  and  atmospheric 
chemical  changes,  which  are  of  great  general 
interest." — Suture. 

"  Tarticular  attention  is  given  to  diseases  from 
worry  and  mental  strain,  from  the  passions,  from 
alcohol,  tobacco,  narcotics,  food,  impure  air,  late 
hom-s,  and  broken  sleep,  idleness,  intermarriage, 
etc.,  thus  toucliiug  upon  causes  which  do  not  enter 
into  the  consideration  of  sickness." — Boston  Com- 
monivealth. 


ROBINSON".  A  Manual  of  Dermatology.  B3-  A.  R.  Robinson, 
M.  B.,  L.  R.  C.  P.  and  S.  (Edinburgh),  Professor  of  Dermatology  at  the 
New  York  Polyclinic  ;  Pi'ofessor  of  Histology  and  Pathological  Anatomy 
at  the  Woman's  Medical  College  of  the  New  York  Infirmary.  Revised 
and  corrected.     8vo.     647  pages.     Cloth,  $5.00. 

"  It  includes  so  much  good,  original  work,  and 
so  well  illustrates  the  best  practical  teaching  of 
the  subject  by  our  most  advanced  men,  that  I  re- 
gard it  as  commanding  at  once  a  place  in  the  very 
front  rank  of  all  authorities.  .  .  .  " — jAiiES 
Nevins  Hyde,  M.  D. 


"  Dr.  Robinson's  experience  has  amply  quali- 
fied him  for  the  task  which  he  assumed,  and  he 
has  given  us  a  book  which  commends  itself  to  the 
consideration  of  the  general  practitioner." — Medi- 
cal Age. 


"  In  general  appearance  it  is  similar  to  Duhr- 
ing's  excellent  book,  more  valuable,  however,  in 
that  it  contains  much  hiter  views,  and  also  on  ac- 
count of  the  excellence  of  the  anatomical  descrip- 
tion accompanying  the  microscopical  appearances 
of  the  diseases  spoken  of." — St.  Louis  Medical  and 
/Surgical  Journal. 

"  Altogether  it  is  an  excellent  work,  helpful  to 
every  one  who  consults  its  pages  tor  aid  in  the  study 
of  skin-diseases.  Ko  physician  who  studies  it  will 
regret  placing  it  in  liis  \ihrary .''''  —Detroit  Lancet. 


ROSCOE  AND  SCHORLEMMER.  A  Treatise  on  Chemistry. 
By  H..R.  RoscoE,  F.  R.  .S,,  and  C.  Schorlemmer,  F.  R.  S.,  Professors  of 
Chemistry  in  the  Victoria  University,  Owens  College,  Manchester.    Illus. 

Inorganic  Chemistry.  8vo.  Vol.  I :  Nox-Metallic  Elements.  15.00. 
Vol.  II,  Part  I  :  Metals.     83.00.     Vol.  II,  Part  II  :  Metals.     $3.00. 

Organic  Chemistry.  8vo.  Vol.  Ill,  Part  I  :  The  Chemistry  of  the 
Hydrocarbons  and  their  Derivatives.  15.00.  Vol.  Ill,  Part  II :  The 
Same.  85.00.  Vol.  Ill,  Part  III  :  The  Same.  Cloth,  83.00.  Vol.  Ill, 
Part  IV  :  The  Same.  Cloth,  83.00.  Vol.  Ill,  Part  V  :  The  Same. 
Cloth,  83.00. 


Specimen  of   Illubteation. 


CATALOGUE  OF  MEDICAL   WOBKS. 


41 


"  It  has  been  tlie  aim  of  the  authors,  in  writLng  their  present  treatise,  to  place  before  the  reader  a 
fairly  complete  and  yet  a  clear  and  succinct  statement  of  the  facts  of  Modern  Chemistry,  while  at  the 
same  time  entering  so  far  into  a  discussion  of  chemical  theory  as  the  size  of  the  work  and  the  present 
transition  state  of  the  science  will  permit. 

"  Special  attention  has  been  paid  to  the  accurate  description  of  the  more  important  processes  in  tech- 
nical chemistry,  and  to  the  careful  representation  of  the  most  approved  forms  of  apparatus  employed. 

"  Much  attention  has  likewise  been  given  to  the  representation  of  apparatus  adopted  for  lecture-room 
experiment,  and  the  numerous  new  illustrations  required  for  this  purpose  have  all  been  taken  from 
photographs  of  apparatus  actually  in  use." — Extract fi'om  Preface. 


"  The  authors  are  evidently  bent  on  making 
their  book  the  finest  systematic  treatise  on  modern 
chemistry  in  the  English  language,  an  aim  in 
which  they  are  well  seconded  by  tlieir  publishers, 
who  spare  neither  pains  nor  cost  in  illustrating  and 
otherwise  setting  forth  the  work  of  these  cListin- 
gTiished  chemists." — London  AtTienmum. 

"  It  is  difl&cult  to  praise  too  highly  the  selection 
of  materials  and  their  arrangement,  or  the  wealth 
of  illustrations  which  explain  and  adorn  the  text. 
In  its  woodcuts,  in  its  technological  details,  in  its 
historical  notices,  in  its  references  to  original  me- 
moirs, and,  it  may  be  added,  in  its  clear  type, 
smooth  paper,  and  ample  margins,  the  volume  un- 
der review  presents  most  commendable  features. 
Whatever  tests  of  accuracy  as  to  figures  and  facts 
we  have  been  able  to  apply  have  been  satisfactorily 


met,  while  in  clearness  of  statement  this  volume 
leaves  nothing  to  be  desired.  Moreover,  it  is  most 
satisfactory  to  find  that  the  progress  of  this  valu- 
able work  toward  completion  is  so  rapid  that  its 
beginning  will  not  have  become  antiquated  before 
its  end  has  been  reached — no  uncommon  occur- 
rence with  elaborate  treatises  on  natural  science 
subjects." — London  Academy. 

"  We  have  no  hesitation  in  saying  that  this  vol- 
ume fully  keeps  up  the  reputation  gained  by  those 
that  preceded  it.  There  is  the  same  masterly 
handling  of  the  subject-matter  ;  the  same  diligent 
care  has  been  bestowed  on  hunting  up  all  the  old 
history  connected  with  each  product.  It  is  this 
that  lends  so  great  a  charm  to  the  whole  work,,and 
makes  it  very  much  more  than  a  mere  text-book." 
—Saturday  Review. 


ROSENTHAli.  General  Physiology  of  Muscles  and  Nerves. 
By  Dr.  I.  Rosenthal,  Professor  of  Physiology  at  the  University  of  Er- 
langen.     With  75  Woodcuts.     12mo.     Cloth,  11.50. 


"  Dr.  Eosenthal  claims  that  the  present  work  is 
the  '  first  attempt  at  a  connected  account  of  general 
physiology  of  muscles  and  nerves.'  This  being  the 
ease.  Dr.  Rosenthal  is  entitled  to  the  greatest  credit 
for  his  clear  and  accurate  presentation  of  the  ex- 
perimental data  upon  which  must  rest  all  future 
knowledge  of  a  very  important  branch  of  medical 
and  electrical  science.  The  book  consists  of  317 
pages,  with  seventy-five  woodcuts,  many  of  whicii 
represent  physiological  apparatus  devised  by  tliu 
author  or  by  his  friends.  Professor  Du  Bois-Rey- 
mond  and  Helmholtz.  It  must  be  regarded  as  in- 
dispensable to  all  future  courses  of  medical  study." 
— New  Yorh  Herald. 

"  Although  this  work  is  written  for  the  instruc- 
tion of  students,  it  is  by  no  means  so  technical 


and  recondite  as  to  be  unprofitable  or  uninterest- 
ing to  the  inquiring  general  reader." — Neiv  Yorh 

Observer. 

"In  this  volume  an  attempt  is  made  to  give 
a  connected  account  of  the  general  physiology 
of  muscles  and  nerves,  a  subject  which  has 
never  before  had  so  thorough  an  exposition  in 
any  text-book,  although  it  is  one  which  has 
many  points  of  interest  for  every  cultivated 
man  who  seeks  to  be  well  informed  on  all 
branches  of  the  science  of  life.  This  work  sets 
before  its  readers  all,  even  the  most  intricate, 
phases  of  its  subject  with  such  clearness  of 
expression  that  any  educated  jjcrson  though 
not  a  specialist  can  comprehend  it." — New  Ha- 
ven Palladium. 


SAYRE.    A  Practical  Manual  on  the  Treatment  of  Club-foot. 

By  Lewis  A.  Sayre,  M.  D.,  Professor  of  Orthopaedic  Surgery  and  Clinical 
Surgery  in  Bellevue  Hospital  Medical  College  ;  Consulting  Surgeon  to 
Bellevue  Hospital,  Charity  Hospital,  etc.,  etc.  Fourth  edition,  enlarged 
and  corrected.     12mo,     Illustrated.     Cloth,  $1.25. 

''  A  more  extensive  experience  in  the  treatment  of  club-foot  has  proved  that  the  doctrines  taught  in 
my  first  edition  were  correct,  viz.,  that  in  all  cases  of  congenital  club-foot  the  treatment  should  com- 
mence at  birth,  as  at  that  time  there  is  generally  no  difficulty  that  can  not  be  overcome  by  the  ordinary 
family  physician  ;  and  that,  by  following  the  simple  rules  laid  down  in  this  volume,  the  great  majority 
of  cases  can  be  relieved,  and  many  cured,  without  any  operation  or  surgical  interference.  If  this  early 
treatment  has  been  neglected,  and  the  deformity  has  been  permitted  to  increase  by  use  of  the  foot  in  its 
abnormal  position,  surgical  aid  may  be  requisite  to  overcome  the  difficulty  ;  and  I  have  here  endeavored 
to  clearly  lay  down  the  rules  that  should  govern  the  treatment  of  this  class  of  cases." — Preface. 

"  The  book  will  very  well  satisfy  the  wants  of  use,  as  stated,  it  is  intended." — Neio  Yorh  Medi- 
the   majority  of  general   practitioners,  for  whose     col  Journal. 


42 


D.  APPLETON  <&    CO:S  ILLUSTRATED 


SAYRE.    Lectures  on  Orthopaedic  Surgery  and  Diseases  of  the 

Joints.  By  Lewis  A.  Sayre,  M.  D.,  Professor  of  Ortbopoedic  Surgery 
and  Clinical  Surgery  in  Bellevue  Hospital  Medical  College  ;  Consulting 
Surgeon  to  Bellevue  Hospital,  Charity  Hospital,  etc.,  etc.  Second  edition, 
revised  and  greatly  enlarged.  324  Illustrations.  8vo.  569  pages.  Cloth, 
$5.00;  sheep,  S6.00. 

This  edition  has  been  thoroughly  revised  and  rearranged,  and  the  subjects  classified  in  the  anatom- 
ical and  pathological  order  of  their  development.  Manv  of  the  chapters  have  been  entirely  rewritten, 
and  several  new  ones  added,  and  the  whole  work  brought  up  to  the  present  time,  with  all  the  new  im- 
provements that  have  been  developed  in  this  department  of  surgery.  Many  new  engravings  have  been 
added,  each  illustrating  some  special  point  iu  practice. 

Specimens  of  Iliustkations. 


"  The  name  of  the  author  is  a  sufficient  guar- 
antee of  its  excellence,  as  no  man  in  America  or 
elsewhere  has  devoted  such  unremitting  attention 
for  the  past  thirty  years  to  this  department  of  sur- 
gerv,  or  given  to  the  profession  so  many  new  truths 
and  laws  as  applying  to  the  pathology  and  treat- 
ment of  deformities." — Western  Lancet. 

"  The  name  of  Lewis  A.  Sayre  is  so  intimately 
connected  and  identified  with  orthopaedics  in  all  its 
branches,  that  a  book  relating  his  e.vperience  can 
not  but  form  an  epoch  in  medical  science,  and 
prove  a  blessing  to  the  profession  and  humanity. 
Dr.  Sayre's  views  on  many  points  difier  from  those 
entertained  by  other  surgeons,  but  the  great  suc- 
cesses he  has  obtained  fully  warrant  him  in  main- 
taining the  '  courase  of  his  opinions.'  " — American 
Journal  of  Obstetrics. 

"  Dr.  Sayre  has  stamped  his  individuality  on 
every  part  of  his  book.  Possessed  of  a  taste  for 
mechanics,  he  has  admirably  utilized  it  in  so  modi- 
fying the  inventions  of  others  as  to  make  them  of 
far  greater  practical  value.  The  care,  patience, 
and  perseverance  which  he  exhibits  in  fulfilling  all 
the  conditions  necessary  for  success  in  tlie  treat- 
ment of  this  troublesome  class  of  cases  are  worthy 
of  all  praise  and  imitation." — Detroit  Heview  of 
Medicine. 


"  Its  teaching  is  sound,  and  the  originality 
throughout  very  pleasing ;  in  a  word,  no  man 
should  attempt  the  treatment  of  deformities  of 
joint  affections  without  being  familiar  with  the 
Views  contained  in  these  lectures."  —  Canada 
Medical  and  Surgical  Journal. 

"...  Taken  as  a  whole,  the  book  will  prove  a 
valuable  addition  to  the  library  of  the  general 
practitioner,  as  well  as  the  orthopa?dist,  both  as  a 
work  of  reference  and  as  a  guide  to  the  principles 
and  practice  pertaining  to  this  much-neylected 
branch  of  surgery,  and  it  should  meet  with  the 
general  commendation  it  deserves."  —  Medical 
Record. 

".  .  .  It  is  a  book  of  expedients  rather  than  of  dry 
pathological  details,  although  this  foundation  of 
treatment  is  by  no  means  neglected.  On  tumin» 
over  it*  pases,  there  will  be  found  those  practical 
applications  of  the  healing  art  which  are  acquired 
by  extended  experience,  and  which  prove  of  ines- 
timable value  to  the  general  practitioner.  .  .  . 
Few  books  have  the  pei-sonality  of  their  authors 
more  forcibly  impressed  upon  them  than  this  one. 
This  fact  gives  piquancy  and  interest  to  the 
volume,  and  the  reader  of  it  will  rise  from  its 
perusal  with  the  impression  that  its  author  ha.s 
written  of  that  he  has  had  experience  in,  and  that 


CATALOGUE  OF  MEDICAL   WORKS.  43 

the  extent  of  Dr.  Say  re's  experience  ffives  weight  most  complete  expression  of  our  knowledge  of  this 

to  his  opinions.  .  .  .  Every  surgeon  who  has  to  do  branch   of  science  for  a  long  time  to   come." — 

with  the  subjects  of  which  it  treats  will  do  wisely  Medical  and  Surgical  Reporter. 
to  have  this  volume  within  easy  reach  upon  his  ,,  _.,        ,.^.         „  ^„„„     .,,  ,      ^, 

sh&lvQs.'' —  American    Journal    of   the   Medical  ■  ■  ■  The  edition  of  I880  will  be  the  one  for 

Sciences  present  consultations  on  all  subjects  relating  to 

orthopaedics.  .  .  .  He  who  does  not  now  recognize 

'' .  .  .  There   is  no  higher  authority   on   de-  Dr.  Sayre  as  the  author  of  the  age,  on  most  all 

formities  and  chronic  diseases  of  joints  than  Dr.  orthopsedic    questions,    almost    thereby   confesses 

Sayre  among  living  surgeons.     His  words  contain  himself  ignorant  of  what  has  been  accomplished 

the  results  of  almost  unequaled  observations,  and  in  this  special  line  of  practice." —  Virginia  Medi- 

we  doubt  not  this  treatise  will  be  received  as  the  cal  Monthly. 

SCHROEDER.  A  Manual  of  Midwifery.  Including  the  Pathology 
of  Pregnancy  and  the  Puerperal  State.  By  Dr.  Cael  Scheoeder,  Pro- 
fessor of  Midwifery  and  Director  of  the  Lying-in  Institution  in  the  Uni- 
versity of  Erlangen.  Translated  from  the  third  German  edition  by 
Charles  H.  Carter,  B.  A.,  M.  D.,  B.  S.,  London,  Member  of  the  Royal 
College  of  Physicians,  London.  With  26  Engravings  on  Wood.  8vo. 
388  pages.     Cloth,  $3.50  ;  sheep,  $4.50. 

"  The  translator  feels  that  no  apology  is  needed  in  oifering  to  the  profession  a  translation  of  Schroe- 
der's  '  Manual  of  Midwifery.'  The  work  is  well  known  in  Germany,  and  extensively  used  as  a  text- 
book ;  it  has  already  reached  a  third  edition  within  the  short  space  of  two  years,  and  it  is  hoped  that 
the  present  translation  ^vill  meet  the  want,  long  felt  in  this  country,  of  a  manual  of  midwifery  embrac- 
ing the  latest  scientific  researches  on  the  subject." 

SCHXJLTZE.     The  Pathology  and  Treatment  of  Displacements 

of  the  Uterus.  By  Dr.  B.  S.  Schultze,  Professor  of  Gynaecology, 
Director  of  the  Lying-in  Institution,  and  of  the  Gynaecological  Clinic,  in 
Jena.  Translated  from  the  German  by  Jameson  J.  Macan,  M.  A.,  M.  R, 
C.  S.  Eng.,  etc.  ;  and  edited  by  Arthur  V.  Macan,  M.  B.,  M.  Ch.,  etc., 
Master  of  the  Rotunda  Hospital,  Dublin.  With  120  Illustrations.  8vo. 
378  pages.     Cloth,  $3.50. 

"American  gynaecologists  will  heartUy  welcome  perts  in  this  branch  of  medicine,  culled  from  an 

this  translation  of  Professor  Schultze' s  work  on  enormous  quantity  of  modern  literature.    The  book 

uterine  displacements  into  the  English  language,  contains   much   original   matter.   .   .   .   The   work 

The  translation  has  been  very  well  done,  and  the  partakes  of  a  scientific  character  throughout,  and 

ideas  of  the  author  turned  into  good,  easy  English,  will  doubtless  be  well  received  by  the  profession." 

The  notes  by  the  editor  are  valuable   and  well-  — Pacific  Medical  Journal. 
timed.  .  .  .  It's  a  book  that  will   richly  repay  a 

careful  study."— Peoria  Medical  Monthly.  "...  In  the  interests  of  gynsccology  we  trust 

.                  .  that  this  work  may  have  a  large  circulation."  — 

"The  author  of  this  work,  it  is  very  evident,  American  Lancet. 
has  bestowed  upon  it  a  vast  amount  of  research. 

He  therefore  gives  his  readers  the  benefit  not  only  "  The  work,  as  a  whole,  is  the  most  elaborate 

of  his  own  rich,  individual  experience,  but  also  of  any  extant  upon  the  subject,  and  worthy  a  place 

presents  them  with  the  best  thoughts  of  other  ex-  in  our  library." — New  Tm'h  Medical  Times. 


SHEARS.  The  N'ew  York  Medical  Journal  Visiting-List  and 
Complete  Pocket  Account-Book.  Prepared  by  Charles  H. 
Shears,  A.  M.,  M.  D.     Price,  $1.25. 

This  List  is  based  upon  an  entirely  new  plan,  the  result  of  an  effort  to  do  away  with  the  defective 
method  of  keeping  accounts  found  in  all  visiting-lists  hitherto  published.  Each  page  is  arranged  for 
the  accounts  of  three  patients,  to  the  number  of  thirty-one  visits  each,  which  may  have  been  inade 
during  a  current  month  or  may  extend  over  a  number  of  months,  according  to  the  frequency  of  the  visits.^ 
With  "the  simple  system  here'inaugurated,  the  practitioner  can  at  a  glance,  and  without  the  trouble  of 
tracing  the  narrow  columns  found" in  the  ordinary  lists,  ascertain  the  condition  of  the  account  of  any 
patient;  when,  and  liow  many  visits  have  been  made  ;  what  has  been  paid,  and  how  much  is  still  due. 
Jt  is  provided  with  an  Index,  and  is,  without  doubt,  the  most  perfect  Visiting-List  ever  offered  to  the  pro- 
fession, as  it  possesses  all  the  advantages  without  the  objectionable  features  found  in  all  others.     Its  use 

OAK  BE   BEGUN   AT   ANT   TIME. 


u 


D.  APPLETON  &    CO:S  ILLUSTRATED 


SHOEMAKER.  A  Text-Book  of  Diseases  of  the  Skin.  By  John 
V.  Shoemaker,  A.  M.,  ^L  D.,  Professor  of  Dermatology  in  the  Medico- 
Chirurgical  College  of  Philadelphia.  8vo.  With  Six  Chromo-Lithographs 
and  numerous  Engravings.     Cloth,  $5.00  ;  sheep,  $6.00. 


8PEC1MEN8   OF    IlLUSTKATIONS. 


"  .  .  .  It  is  a  treatise  on  the  skin  which  we  can 
recommend  to  every  physician  as  a  work  of  refer- 
ence, and  in  which  he  will  find  the  latest  views  on 
pathology  and  treatment.  At  the  end  of  the  work 
are  a  number  of  formulae,  which  will  prove  very 
valuable  as  a  reference.  It  is  certainly  a  very  com- 
plete book." — Canada  Lancet. 

"  This  is  an  entirely  new  work  upon  diseases  of 
the  skin,  by  one  who  evidently  has  had  very  large 
observation  and  experience  in  those  affections. 
.  .  .  Students  and  physicians  will  find  it  well 
adapted  to  their  wants.  A  proper  study  of  it  will 
give  them  a  very  satisfactory  knowledge  of  skin 
affections." — Cincinnati  Medical  News. 


".  .  .  Dr.  Shoemaker's  excellent  work 
will  be  especially  acceptable  to  the  profes- 
sion as  being  free  from  cumbrous  techni- 
cality, and  as  having  been  prepared  to 
interest  and  instruct  the  practitioner,  and 
not  to  embarrass  him  with  burdensome 
details  that  might  make  the  study  and  the 
subject  a  tax  rather  than  a  pleasure." — 
College  and  Clinical  Record. 

"  This  treatise,  by  a  well-known  writer 
and  authority  upon  diseases  of  the  skin, 
will  doubtless  receive  a  warm  welcome 
from  the  profession.  It  is  everything  a 
text-book  should  be,  concise,  clear,  ex- 
haustive, and  well  illustrated.  We  un- 
hesitatingly recommend  it  to  all  physicians 
and  students." — Nashville  Journal  of 
Medicine. 

"  Every  practitioner  has  frec|uent  need 
for  a  concise,  practical,  and  reliable  guide 
in  the  diagnosis  and  treatment  of  skin 
diseases — a  book  free  from  the  cumbrous 
technicalities  which  oftener  mislead  than 
instruct.  Such  is  the  work  before  us,  and 
we  think  our  readers  will  thank  us  for 


advising  them   to  buy  it,  if  they  desire   a  good 
authority  on  diseases  of  the  skin." — Practice. 

"  Of  the  many  works  issued  in  the  past  few 
years  on  dermatology.  Dr.  Shoemaker's  book  bids 
fair  to  rival  its  predecessors  in  this  particular 
branch  of  medical  science.  Every  part  is  quite  up 
to  the  requirements  of  a  modern  book  of  refer- 
ence, and  the  whole  is  agreeably  stamped  with  the 
individuality  of  the  author,  showintc  clearly  that  it. 
is  not  a  mere  compilation  but  is  the  pniduct  of  an 
original  investigator  and  an  experienced  observer. 
The  excellent  work  of  Appleton  &  Co.  is  apparent 
in  the  binding  and  typographical  part." —  Western 
Medical  Reporter. 

"  No  physician  in  this  country  is  better  fitted, 
by  personal  experience,  to  give  the  profession  a. 
text-book  on  skin  diseases  than  Dr.  Shoemaker. 
The  work  before  us  is  one  of  great  merit,  and  is  a 
complete  treatise  on  the  whole  subject.  It  has  a 
number  of  beautifully  colored  plates  illustrating- 
the  text.  No  class  of  diseases  is  so  troublesome  as 
that  of  the  skin,  and  this  valuable  book  will  be 
welcomed  by  the  profession." — Southern  Clinic. 

"A  very  careful  examination  leads  to  the  con- 
clusion that  Shoemaker's  '  Diseases  of  the  Skin  'is- 
destined  to  become  the  leading  work  of  its  kind  in 
America." — Kansas  City  Medical  Index. 

"  For  the  general  practitioner,  this  is  the  text- 
book he  shoidd  adopt  for  practical  purposes.  De- 
scriptions are  good ;  diagnostic  points  between 
diseases  bearing  a  similar  phase  are  clearly  made ; 
the  drawings  well  delineate  the  distinctive  features 
of  special  diseases  ;  and,  above  all,  the  therapeutics 
suited  to  given  cases  are  well  indicated." — Vir- 
ginia Medical  Monthly. 

"  We  shall  not  be  accused  of  over-patriotic-, 
zeal  if  we  recommend  Dr.  Shoemaker's  book  as. 
the  preferable  one  tor  American  physicians  and 
students.  His  style  is  simplicity  itself,  and  there- 
in has  he  scored  his  greatest  success  over  other- 
authors  we  mitfht  name." — Medical  Record. 


CATALOGUE  OF  MEDICAL    WORKS. 


45 


SIMPSON.  The  Posthumous  Works  of  Sir  James  Young 
Sim.pson,  Bart.,  M,  D.  In  Three  Volumes.  Vol.  I. — Selected  Ob- 
stetrical AND  Gynaecological  Works  Op  Sir  James  Y.  Simpson. 
Edited  by  J.  Watt  Black,  M.  D.  8vo.  852  pages.  Cloth,  13.00  ; 
sheep,  14.00. 

This  first  volume  contains  many  of  the  papers  reprinted  from  his  Obstetric  Memoirs  and  Contrilju- 
tions,  and  also  his  Lecture  Notes',  now  published  for  the  first  time,  containing  the  substance  of  the 
practical  part  of  his  course  of  midwifery.  It  is  a  volume  of  great  interest  to  the  profession,  and  a  fitting 
memorial  of  its  renowned  and  talented  author. 

Vol.  II. — Anesthesia,  Hospitalism,  etc.  Edited  by  Sir  Walter  Simpson, 
Bart.     8vo.     560  pages.     Cloth,  $3.00  ;  sbeep,  14.00. 

Vol.  III. — Diseases  of  Women.  Edited  by  Alexander  Simpson,  M.  D. 
8vo.     789  pages.     Cloth,  13.00  ;  sheep,  $4.00. 

One  of  the  best  works  on  the  subject  extant.     Of  inestimable  value  to  every  physician. 

SIMS.  The  Story  of  My  Life.  By  the  late  J.  Marion  Sims,  M.D. 
Edited  by  his  Son,  H.  Marion  Sims,  M.  D.  With  Portrait.  12mo. 
Cloth,  11.50. 


Specimen  of  Illustration. 


SKENE.     Treatise  on  the  Diseases  of  Women.     For  the  Use  of 

Students  and  Practitioners.  By  Alexander  J.  C.  Skene,  M.  D.,  Profes- 
sor of  Gynaecology  in  the  Long  Island  College  Hospital,  Brooklyn,  N.  Y. ; 
formerly  Professor  of  Gynaecology  in  the  New  York  Post-graduate  Medi- 
cal School  and  Hospital,  etc.  8vo.  966  pages.  Illustrated  with  251  Fine 
Engravings  and  Nine  Chromo-lithographs.  Cloth,  $6.00  ;  sheep,  $7.00. 
Sold  by  subscription  only. 

"  If  asked  to  select  a  guide  for  the  practitioner 
in  his  daily  work,  we  would  unhesitatmgly  name 
Dr.  Skene's  book.  Its  strong  points  are  its  con- 
servatism and  its  minute  consideration  of  the  non- 
operative  measures  at  our  disposal.  The  author 
never  advises  a  method  of  treatment  merely  be- 
cause it  has  the  sanction  of  a  great  name  ;  he  care- 
fully tries  the  proposed  remedy  and  decides  solely 
according  to  the  results.  The  illustrations  are 
good,  many  of  them  excelling  those  found  in  any 
other  text-book.  The  histories  of  cases  appended 
to  each  subject  are  an  invaluable  aid.  To  master 
these  portions  of  the  work  alone  would  give  the 
reader  a  very  fair  knowledge  of  the  whole  sub- 
ject."— Southern  Galifornia  Practitioner. 

' '  We  commend  this  volume  to  all  students  and 
others  whose  knowledge  of  gynajcology  is  either 
confused  or  rusty.  It  will  be  found  useful  as  a 
final  reference  before  examinations.  The  author 
deserves  great  credit  for  the  amount  of  patient 
labor  he  has  expended  in  making  the  work  so 
comprehensive  and  clear." — University  Medical 
Magazine. 

"  To  Professor  Skene  undoubtedly  belongs  the 
credit  of  having  written  the  book  of  the  "year; 
nothing  that  has  appeared  during  the  season  can 
be  compared  with  it.  There  has  long  been  a  need 
for  a  text-book  that  should  comprehend  all  the 
recent  advances  in  gynsecology,  yet  not  be  so 
•long-drawn-out'  as  to  be  tedious.  Professor 
Skene  has  given  this — writing  in  an  attractive 
style,  yet  in  teiTQs  so  plain  as  to  be  unmistakable  ; 
the  work  bears  upon  the  face  of  it  the  fact  that  it 
is  the  outgrowth  of  the  experience  of  the  author 
in  a  long  and  active  professional  life,  devoted 
almost  exclusively  to  the  treatment  of  diseases  of 


women.  It  seems  to  be  written,  however,  not 
from  the  standpoint  of  a  '  specialist,'  but  fi'om  that 
of  the  general  practitioner  who  sees  there  is  a 
woman  beyond  the  uterus — whose  professional  eye 
is  not  confined  to  what  can  be  seen  through  a 
speculum.  Again,  the  author  has  not  given  way 
to  the  surgical  furor  that  now  agitates  the  (medi- 
cal) world,  but,  while  giving  due  attention  to  the 
surgical  procedures,  at  the  same  time  has  kept 
constantly  in  mind  the  medical  treatment  of  all 
diseases  liable  to  yield  to  medication  alone.  But, 
better  than  all,  he  has  manifested  no  tendency  to 
'ride  a  hobby,'  as  has  been  the  case  with  all' his 


46 


D.  AFPLETON  &    CO:S  ILLUSTRATED 


Specimen  of  Illustbatton. 


predecessors  in  this  department  of  medical  litera- 
ture ;  all  diseases  are  considered  briefly  or  exten- 
sively in  accordance  with  their  dcirree  of  im- 
portance, and  many  subjects  not  hitherto  specially 
mentioned  are  given  the  prominence  they  deserve. 
This  is  especially  the  case  with  diseases  of  the 
bladder  and  urethra — a  class  little  understood  by 
the  average  physician,  yet  of  prime  importance ; 
so,  too,  of  the  abuse  of  pessanes,  jiynsecology  as 
related  to  insanity,  and,  best  of  all,  the  use  of 
electricity  in  the  treatment  of  uterine  tumors." — 
Kansas  City  Medical  Index. 

"  We  regard  the  book  as  one  of  the  best  extant 
on  gynaecology,  and  especially  so  for  the  student 
and  general  practitioner ;  and  we  think  that  but 
few  specialists  can  read  it  without  profit  as  well  as 
pleasure.  The  illustrations  are  of  more  than  usual 
excellence,  and  many  of  them  are  original.  The 
printing  also  is  good,  but  the  paper  is  rather 
poor." — Medical  and  Surgical  Reporter. 


"The  name  of  Skene  will  cause  the  reader  to 
open  this  volume  with  an  eager  interest  tliat  will 
be  amply  justified.  In  the  plan  adopted  in  this 
book,  the  diseases  of  women  are  divided  into  three 
classes,  viz.  :  Those  which  occur  between  birth  and 
puberty,  those  between  puberty  and  the  meno- 
pause, and  those  which  come  alter  the  menopause. 
Each  subject  being  briefly  described  with  history 
of  cases,  typical  and  complicated,  which  are  given 
as  illustrative  of  the  disease  or  injury  under  con- 
sideration, with  the  author's  method  of  treatment. 
In  carrying  out  this  plan,  the  history  of  gynaecology 
and  the  discussion  of  all  disputed  questions  have 
been  omitted  as  being  at  variance  with  scope 
adopted.  Taken  altogether,  we  find  that  it  is  one 
of  the  very  best  books  extant  on  the  subject  of 
gynaecology,  and  we  can  not  too  warmly  com- 
mend it  to  the  readers  of  the  New  England, 
Monthly.'" 


SMITH.    Health :  A  Hand-Book  for  Households  and  Schools. 

By  Edward  Smith,  M.  D.,  F.  R.  S.,  Fellow  of  the  Royal  College  of  Phy- 
sicians and  Surgeons  of  England,  etc.  12mo.  Illustrated.  198  pages. 
Cloth,  $1.00. 

It  is  intended  to  inform  the  mind  on  the  subjects  involved  in  the  word  Health  to  show  how  health 
may  be  retained  and  ill-health  avoided,  and  to  add  to  the  pleasure  and  usefulness  of  life. 


"The  author  of  thus  manual  lias  rendered  a 
real  service  to  families  and  teachers.  It  Ls  not  a 
mere  treatise  on  health,  such  as  would  be  -m-itten 
by  a  medical  professor  for  medical  students.  Nor 
is"  it  a  treatise  on  the  treatment  of  disease,  but 
a  plain,  common-sense  ess.ay  on  the  prevention 
of  most  of  the  ills  that  flesh  is  heir  to.  There 
is   no   doubt    that   much    of   the    sickness    with 


which  humanity  is  afflicted  is  the  result  of  igno-    —Albany  Journal. 


ranee,  and  proceeds  from  the  use  of  improper 
food,  from  ciefective  drainage,  overcrowded  rooms, 
ill-ventilated  workshops,  impure  water,  and  other 
like  preventable  causes.  Legislation  and  munici- 
pal regulations  may  do  something  in  the  line 
of  prevention,  but  the  people  themselves  can  do 
a  great  deal  more — particularly  if  properly  en- 
lightened ;  and  this  is  the  purj^ose  of  the  book." 


SMITH.  On  Foods.  By  Edward  Smith,  M.  D.,  LL.  B.,  F.  R.  S.  Fellow 
of  the  Royal  College  of  Physicians  of  London,  etc.,  etc.  12mo.  485 
pages.     Cloth,  81.75. 


"  Since  the  issue  of  the  author's  work  on  '  Prac- 
tical Dietary,'  he  has  felt  the  want  of  another, 
which  would  embrace  all  the  generally  known  and 
some  less  known  foods,  and  contain  the  latest  scien- 


tific knowledge  respecting  them.  The  present  vol- 
ume is  intended  to  meet  this  want,  and  will  be 
found  useful  for  reference,  to  both  scientific  and 
general  readers.    The  author  extends  the  ordinary 


CATALOGUE  OF  MEDICAL   WORKS. 


47 


view  of  foods,  and  includes  water  and  air,  since 
they  are  important  both  in  their  food  and  sanitary 
aspects.  The  book  contains  a  series  of  diagrams, 
displaying  the  effects  of  sleep  and  meals  on  pulsa- 
tion and  respiration,  and  of  various  kmds  of  food 
on  respiration,  which,  as  the  results  of  Dr.  Smith's 


own  experiments,  possess  a  very  high  value.  We 
have  not  far  to  go  in  this  work  for  occasions  of 
favorable  criticism  ;  they  occur  throughout,  but  are 
perhaps  most  apparent  in  those  parts  of  the  sub- 
ject with  which  Dr.  Smith's  name  is  especially 
linked." — London  Examiner. 


SMITH.  Diseases  of  Memory  :  An  Essay  in  the  Positive  Psy- 
chology. By  Th.  Ribot,  Author  of  "Heredity,"  etc.  Translated  from 
the  French  by  William  Huntington  Smith.     12rQo.     Cloth,  $1.50. 

ical  associations,  very  stable  and  very  responsive  to 
proper  stimuli.  .  .  .  The  brain  is  like  a  laboratory 
full  of  movement  where  thousands  of  operations 
are  going  on  all  at  once.  Unconscious  cerebration, 
not  being  subject  to  restrictions  of  time,  operating, 
so  to  speak,  only  in  space,  may  act  in  several 
directions  at  the  same  moment.  Consciousness 
is  the  narrow  gate  through  which  a  very  small 
part  of  all  this  work  is  able  to  reach  us.'  M. 
Kibot  thus  reduces  diseases  of  memory  to  law, 
and  his  treatise  is  of  extraordinary  interest." — 
Philadelphia  Press. 


"Not  merely  to  scientitic,  but  to  all  thinking 
men,  this  volume  will  prove  intensely  interesting.'"' 
— New  York  Observer. 

"M.  Eibot  has  bestowed  the  most  painstaking 
attention  upon  his  theme,  and  numerous  examples 
of  the  conditions  considered  greatly  increase  the 
value  and  interest  of  the  volume." — Philadelphia 
North  American. 

" '  Memory,'  says  M.  Kibot,  '  is  a  general  func- 
tion of  the  nervous  system.  It  is  based  upon  the 
faculty  possessed  by  the  nervous  elements  of  con- 
serving a  received  modification,  and  of  forming  as- 
sociations.' And  again  :  '  Memory  is  a  biological 
fact.  A  rich  and  extensive  memory  is  not  a  collec- 
tion of  impressions,  but  an  accumulation  of  dynam- 


"  It  is  not  too  much  to  say  that  in  no  single 
work  have  so  many  curious  cases  been  brought 
together  and  intei-preted  in  a  scientific  manner." 
— Boston  Evening  Traveller. 


STEINEE,.  Compendium  of  Children's  Diseases.  A  Hand-Book 
for  Practitioners  and  Students.  By  Dr.  Johann  Steineb,  Professor  of 
the  Diseases  of  Children  in  the  University  of  Prague.  Translated  from 
the  second  German  edition  by  Lawson  Tait,  F.  R.  C.  S.,  Surgeon  to  the 
Birmingham  Hospital  for  Women.     8vo.     Cloth,  $3.50  ;  sheep,  14.50. 

"  Dr.  Steiner's  book  has  met  with  such  marked  success  in  Germany  that  a  second  edition  has  already 
appeared,  a  circumstance  which  has  delayed  the  appearance  of  its  English  form,  in  order  that  I  might 
be  able  to  give  his  additions  and  corrections. 

"I  have  added  as  an  Appendix  the  'Eules  for  Management  of  Infants  '  which  have  been  issued  by 
the  staff  of  the  Birmingham  Sick  Children's  Hospital,  because  I  think  that  they  have  set  an  example, 
by  freely  distributing  these  rules  among  the  poor,  for  whicli  they  can  not  be  sufficiently  commended, 
and  which  it  would  be  wise  for  other  sick  children's  hospitals  to  follow. 

"I  have  also  added  a  few  notes,  chiefly,  of  course,  relating  to  the  surgical  aUments  of  children." — 
Extract  from  Tixtnslator'' s  Preface. 


STEVEN'S,  Functional  Nervous  Diseases :  Their  Causes  and 
their  Treatment.  Memoir  for  the  Concourse  of  1881-1883,  Academie 
Royale  de  Medecine  de  Belgique.  With  a  Supplement,  on  the  Anomalies 
of  Refraction  and  Accommodation  of  the  Eye,  and  of  the  Ocular  Muscles. 
By  Geokge  T.  Stevens,  M.  D.,  Ph.  D.,  Member  of  the  American  Medical 
Association,  of  the  American  Ophthalmological  Society,  etc.  ;  formerly 
Professor  of  Ophthalmology  and  Physiology  in  the  Albany  Medical  Col- 
lege. Small  8vo.  217  pages.  With  Six  Photographic  Plates  and  Twelve 
Illustrations.     Cloth,  $2.50. 

"  A  careful  study  of  this  work  will  undoubtedly 
clear  up  many  hitherto  illy  understood  cases  of 
nervous  troubles,  and  will  lead  to  a  more  success- 
ful treatment  of  such.  .  .  ." — Peoria  Medical 
Monthly. 

" .  .  .  We  heartily  commend  his  book  to  all 
thoughtful  students  of  nervous  diseases,  feeling 
sure  that  they  can  not  fail  of  finding  in  it  most 
valuable  suggestions."  —  Medical  and  Surgical 
Reporter. 


"...  It  is  fortunate  for  the  profession  that 
Dr.  Stevens  has  done  his  views  full  justice  in  a 
work  to  which  all  can  have  access,  for  they  cer- 
tainly deserve  careful  attention." — Medical  Press 
of  Western  Neio  York. 

".  .  .  The  work  is  eminently  suggestive 
and  practical  upon  numerous  points,  and  must 
prove  interesting  and  very  useful  to  the  stu- 
dent and  practitioner."  —  Southern  Medical 
Record. 


48 


D.  APPLET  OX  &    CO:S  ILLUSTRATED 


STONE.  Elements  of  Modern  Medicine,  including  Principles  of 
Pathology  and  Therapeutics,  with  many  Useful  Memoranda  and  Valuable 
Tables  of  Reference.  Accompanied  by  Pocket  Fever  Charts.  Designed 
for  the  Use  of  Students  and  Practitioners  of  Medicine.  By  R.  French 
Stone,  M.  D.,  Professor  of  Materia  Medica  and  Therapeutics  and  Clinical 
Medicine  in  the  Central  College  of  Physicians  and- Surgeons,  Indianapolis  ; 
Physician  to  the  Indiana  Institute  for  the  Blind  ;  Consulting  Physician  to 
the  Indianapolis  City  Hospital,  etc.,  etc.  In  wallet-book  form,  with  pockets 
on  each  cover  for  Memoranda,  Temperature  Charts,  etc.      $2.50. 


"This  is  an  abridged  work  in  i)oeket-book 
form,  presenting  the  more  advanced  views  of  lead- 
ing autliorities,  with  reference  to  general  pathology 
and  therapeutics.  Under  generarpathology  are  in- 
cluded articles  on  the  origm,  nature,  and  cluration 
of  disease,  chief  symptoms,  diau'nosis,  prognosis, 
and  treatment.  In  the  second  part  will  be  found 
what  is  regarded  by  the  author  as  an  improved 
classification  of  drugs,  followed  by  articles  on  their 
physiological  action,  indications,  and  methods  of 
use.  The  work  contains  a  fund  of  useful  informa- 
tion culled  from  the  best  authorities  in  the  Old  and 
New  World." — Canada  Lancet. 


"  This  is  a  neatly  printed  pocket  manual  of 
medical  practice.  It'is  a  well-condensed  compila- 
tion of  the  kind,  containing  a  short  sketch  of 
nearly  everything  that  is  met  with  in  practice. 
The  "fever  charts"  are  well  arranged,  and  there  is 
a  convenient  therapeutic  table  which  will  be 
found  valuable.  It  will  probably  be  more 
suitable  for  young  practitioners,  on  account  of 
its  containing  many  practical  points  that  are 
not  to  be  found  elsewhere  in  such  a  con- 
densed manner.  It  ■will  be  found  a  valuable 
aid  to  those  just  commencing  practice." — Medi- 
cal Herald. 


STRECKER.  Adolph  Strecker's  Short  Text-Book  of  Organic 
Chemistry.  By  Dr.  Johannes  Wislicenus.  Translated  and  edited, 
with  Extensive  Additions,  by  W.  H,  Hodgkinson,  Ph.  D.,  and  A.  J. 
Greenaway,  F.  I.  C.     8vo.     789  pages.     Cloth,  15.00. 

The  great  popularity  which  Prof.  Wislicenus's  edition  of  "  Strecker's  Text-Book  of  Organic  Chem- 
istry" has  enjoyed  in  Germany  has  led  to  the  belief  that  an  English  translation  will  be  acceptable. 
Since  the  publication  of  the  book  in  Germany,  the  knowledge  of  organic  chemistry  has  increased,  and 
this  has  necessitated  many  additions  and  alterations  on  the  part  of  the  translators. 

Specimkk  of  Illustration. 


"  Let  no  one  suppose 
that  in  this  '  short  text- 
book' we  have  to  deal 
with  a  primer.  Every- 
thing is  comparative,  and 
the  term  '  short '  here  has 
relation  to  the  enormous 
development  and  extent 
of  recent  organic  chem- 
istry. This  solid  and 
comprehensive  volume  is 
intended  to  represent  the 
present  condition  of  the 
science  in  its  main  facts 
and  leading  principles,  as 
demanded  by  the  syste- 
matic chemical  student. 
We  have  here,  probably, 
the  best  extant  text-book 
of  organic  chemistry.  Not 
only  is  it  full  and  com- 
prehensive and  remarka- 
bly clear  and  methodical, 
but  it  is  up  to  the  very 
latest  moment,  and  it  has 
been,  moreover,  prepared 
in  a  way  to  secure  the 
greatest  excellences  in 
such  a  treatise."  —  The 
Popular  Science  Monthly. 


CATALOGUE   OF  MEDICAL   WORKS. 


49 


STRUMPELIi.  A  Text-Book  of  Medicine.  For  Students  and  Prac- 
titioners. By  Adolph  Strumpell,  formerly  Professor  and  Director  of 
the  Medical  Polyclinic  at  the  University  of  Leipsic.  Translated,  by  per- 
mission, from  the  second  and  third  German  editions  by  Herman  F. 
ViCKERY,  A.  B.,  M.  D.,  Assistant  in  Clinical  Medicine,  Harvard  Medical. 
School,  etc.,  and  Philip  Coombs  Knapp,  Physician  to  Out-patients  with 
Diseases  of  the  Nervous  System,  Boston  City  Hospital,  etc.  With 
Editorial  Notes  by  Frederick  C.  Shattuck,  A.  M.,  M.  D.,  Instructor  in 
the  Theory  and  Practice  of  Physic,  Harvard  Medical  School,  etc.  With 
111  Illustrations.     8vo.     981  pages.     Cloth,  16.00  ;  sheep,  17.00. 

"  The  above  werk,  which  is  new  to  most  of  our  Specimen  of  Illitsteation. 

readers,  has  achieved  great  success  in  Germany, 
having  reached  the  third  edition  in  a  very  short 
time.  It  has  been  introduced  as  the  text-book  on 
medicine  in  the  Harvard  Medical  School.  The 
work  is  especially  commendable  in  its  treatment 
of  nervous  diseases,  which  are  dealt  with  fully, 
concisely,  and  clearly.  The  pathology  of  disease, 
as  might  be  expected  from  so  eminent  a  teacher, 
has  received  due  and  careful  attention,  and  this  is 
another  strong  feature  of  the  work.  The  author 
gives  in  this  work  the  results  of  the  experience 
and  observation  of  more  than  six  years'  active 
work  in  the  medical  clinic  in  Leipsic.  We  heartily 
commend  the  work  to  the  attention  of  our  readers." 
— Cariada  Lancet. 

"In  spite  of  the  fact  that  within  the  last  year 
or  two  so  many  excellent  works  on  general  medi- 
cine have  appeared,  we  think  there  will  be  found  a 
place  for  the  volume  before  us.  The  best  part  of 
the  book  is  the  section  devoted  to  nervous  diseases. 
The  various  affections  of  the  nervous  system  are 
discussed  in  a  very  concise  way,  together  with  the 
most  recent  discoveries  in  neuro-patholo^y.  The 
translators  have  done  their  work  well,  and  the  edi- 
tor has  made  a  number  of  important  additions. 
Altogether  the  book  is  a  very  valuable  contribution 
and  compilation,  and  wiU  be  useful  both  to  teacher 
and  practitioner." — Maryland  Medical  Journal. 

"  The  work  before  us  is  one  that  is  peculiarly 
attractive  to  the  student  of  medicine,  not  only  on 
account  of  the  well-delineated  German  plans  of 
treatment,  but  especially  for  the  clear  and  accurate 
pathology  given  by  the  author  in  almost  all  dis- 
eases. Dr.'  Shattuck  states  that  he  is  acquainted 
with  no  work  which  treats  of  the  diseases  of  the 
nervous  system,  in  which  our  knowledge  has  ad- 
vanced so  rapidly  of  late  years,  so  fully,' concisely, 
and  clearly.  Tlie  style  is  clear  for  a  German  work, 
which  as  a  rule  do'  not  make  models  in  this  par- 
ticular. The  translators  have  overcome  the  diflB- 
culties  of  the  original  so  successfully  that  they 
have  made  it  a  decidedly  agreeable  text-book. 
The  book  is  extremely  popular  in  Germany,  hav- 
ing reached  the  third  edition  in  a  comparatively 
short  time,  and  we  do  not  doubt  but  that  its  popu- 
larity in  America  will  soon  be  assured." — Missis- 
sippi Valley  Medical  Monthly. 

"  I  like  it  so  well  that  I  have  commended  it  to 
my  class  and  have  called  special  attention  to  its 
three  hundred  pages  devoted  to  the  nervous  sys- 
tem, bringing  to  date  all  the  knowledge  which  the 
last  ten  years,  more  than  many  centuries  past, 
have  brought  to  the  use  of  the  profession." — 
H.  D.  DiDAiiA,  M.  D.,  Professor  of  the  Principles 
and  Practice  of  Medicine  and  Clinical  Medicine, 
College  of  Medicine,  Syracuse  University. 

"I  consider  it  the  best  text-book  of  medicine 
with  which  I  am  acquainted.    The  part  on  nervous 


diseases  is  so  excellent  that  I  shall  recommend  the 
whole  book  to  my  class  as  a  text-book  on  diseases 
of  the  nervous  system." — Henry  Hun,  M.  D., 
LL.  D.,  Dean  of  the  Faculty  and  Emeritus  Pro- 
fessor of  the  Institutes  of  Medicine,  Albany  Medi- 
cal College. 

"  Of  the  German  text- books  of  practice  that 
have  been  translated  into  English,  Prof.  Strum- 
pell's  will  probably  take  the  highest  rank.  Be- 
tween its  covers  will  be  found  a  very  complete  and 
systematic  description  of  all  the  diseases  which 
are  classed  under  the  head  of  internal  medicine. 
Unlike  most  of  the  larger  works  on  practice,  we 
do  not  find  the  preliminary  discourse  on  general 
pathological  subjects,  an  omission  which  is  very 
much  to  be  commended,  because  there  are  at  the 
present  day  so  many  special  treatises  upon  patho- 
logical subjects  that  there  is  no  longer  a  necessity 
for  such  a  section  in  a  woi-k  of  this  kind.  While  it 
is  impossible  to  refer  to  all  these  particularly,  we 
may  call  attention  to  the  chapter  on  Typhoid 
Fever  as  being  especially  valuable,  not  only  on  ac- 
count of  the  advanced  views  in  regard  to  the  pa- 
thology of  that  disease,  but  also  because  of  the  care- 
ful description  of  its  clinical  history  and  of  its 
treatment.  Taken  altogether,  it  is  one  of  the  most 
valuable  works  on  practice  that  we  have,  and  one 
which  every  studious  practitioner  should  have 
upon  his  shelves." — JS^eiv  York  Medical  Journal. 


50  D.   A  PPL  ETON  &    CO:S  ILLUSTRATED 


THOMAS.  Abortion  and  its  Treatment,  from  the  Standpoint  of 
Practical  Experience.  A  Special  Course  of  Lectures  delivered  before  the 
College  of  Physicians  and  Surgeons,  New  York,  Session  of  1889-'90.  By 
T.  Gaillard  Thomas,  M.  D.,  Emeritus  Professor  of  Obstetrics  and 
Gynaecology.  From  Notes  by  P.  Brynberg  Porter,  M.  D.  Revised 
by  the  Author.     Cloth,  $1.00. 

"  It  is  very  seldom  that  u  work  is  issued  from  of  the  long  and  extended  experience  of  its  author 

the  medical  press  of  as  great  practical  service  to  on  a  subject  upon   which  he  is  qualified  as  few 

the   working  physician   as    this   little   volume   is  others  to  speak." — GaUlard''s  Medical  Journal. 
likely  to  prove,   'in  it  are  presented  the  rich  fruits 


TRACY.  Hand-Book  of  Sanitary  Information  for  House- 
holders. Containing  Facts  and  Suggestions  about  Ventilation,  Drain- 
age, Care  of  Contagious  Diseases,  Disinfection,  Food,  and  "Water.  With 
Appendices  on  Disinfectants  and  Plumbers'  Materials.  By  Roger  S. 
Tracy,  M.  D.,  Sanitary  Inspector  of  the  New  York  City  Health  Depart- 
ment.    16mo.     Cloth,  50  cents. 

"  This  volume  of  about  one  hundred  pages  em-  other  matters  relating  to  the  personal  comfort  and 

bodies  a  great  deal  of  useful  information  upon  the  welfare  of  humanity.  .  .   .  The  language  is  clear, 

subjects  of  air,  ventilation,   drainage,    plumbing,  plain,  and  concise,  and  the  work  will  undoubtedly 

disinfection,  treatment  of  contagious  diseases,  and  find  a  large  sale.  .  .  .  " — Architect  and  Builder. 


TRACY.  The  Essentials  of  Anatomy,  Physiology,  and  Hy- 
giene. By  Roger  S.  Tracy,  M.  D.,  Sanitary  Inspector  of  the  New 
York  City  Health  Department.     12mo.     Cloth,  11.25. 

This  work  has  been  prepared  in  response  to  the  demand  for  a  thoroughly  scientific  and  yet  practical 
text-book  for  schools  and  academies,  which  shall  afford  an  accurate  knowledge  of  the  essential  facts  of 
Anatomy  and  Physiology,  as  furnishing  a  scientific  basis  for  the  study  of  Hygiene  and  the  Laws  of 
Health.  It  also  treats,  in  a  rational  manner,  of  the  physiological  effects  of  alcohol  and  other  narcotics, 
fulfilling  all  the  requirements  of  recent  legislative  enactments  upon  this  subject. 

"It  is  one  of  the  best  of  the  kind  that  I  have  a  work  of  the  kind.    The  illustrations  are  excellent, 

ever  seen.      One  of  the  most  important  features  and  show  that  1  )r.  Tracy  gave  thorough  considera- 

about  the  book  is  the  clear  and  concise  manner  in  tion  to  his  subject." — W.  F.  Coosies,  M.  D.,  Pro- 

whicli  it  is  written — a  thing  much  to  be  desired  in  fessor  of  Physiologi/,  Kentucky  School  of  Medicine. 


TUSON.  Cooley's  Cyclopaedia  of  Practical  Receipts,  and  Col- 
lateral Information  in  the  Arts,  Manufactures,  Professions,  and  Trades, 
including  Medicine,  Pharmacy,  and  Domestic  Economy.  Designed  as  a 
Comprehensive  Supplement  to  the  Pharmacopoeia,  and  General  Book  of 
Reference  for  the  Manufacturer,  Tradesman,  Amateur,  and  Heads  of 
Families.  Sixth  edition,  revised  and  partly  rewritten  by  Richard  V. 
TusoN,  Professor  of  Chemistry  and  Toxicology  in  the  Royal  Veterinary 
College.  Complete  in  Two  Volumes.  1,796  pages.  With  Illustrations. 
Cloth,  19.00. 

Cooley's  "  Cyclopaedia  of  Practical  Receipts"  has  for  many  years  enjoyed  an  extended  reputation 
for  its  accuracv  and  comprehensiveness.  The  sixth  edition,  now  just  completed,  is  larger  than  the  last 
by  some  six  hundred  pages.    Much  greater  space  than  hitherto  is  devoted  to  Hygiene  (including  sanita- 


CATALOGUE  OF  MEDICAL   WORKS. 


51 


tion,  the  composition  and  adulteration  of  foods),  as  well  as  to  the  Arts,  Pharmacy,  Manufacturing 
(Chemistry,  and  other  subjects  of  importance  to  those  for  whom  the  work  is  intended.  The  articles  on 
what  is  commonly  termed  "  Household  Medicine  "  have  been  amplified  and  numerically  increased. 

The  design  of  this  work  is  briefly  but  not  completely  expressed  in  its  title-page.  Independently  of 
a  reliable  and  comprehensive  collection  of  formula  and  processes  in  nearly  all  the  industrial  and  useful 
arts,  it  contains  a  description  of  the  leading  properties  and  applications  of  the  substances  referred  to, 
together  with  ample  directions,  hints,  data,  and  allied  information,  calculated  to  facilitate  the  develop- 
ment of  the  practical  value  of  the  book  in  the  shop,  the  laboratory,  the  factory,  and  the  household. 
Notices  of  the  substances  embraced  in  the  Materia  Medica,  in  addition  to  the  whole  of  their  prepara- 
tions, and  numerous  other  animal  and  vegetable  substances  emploj'ed  in  medicine,  as  well  as  most  of 
those  used  for  food,  clothing,  and  fuel,  with  their  economic  applications,  have  been  included  in  the 
work.  The  synonyms  and  references  are  other  additions  whicli  will  prove  invaluable  to  the  reader. 
Lastly,  there  have  been  appended  to  all  the  principal  articles  referred  to  brief  but  clear  directions  for 
determining  their  purity  and  commercial  value,  and  for  detecting  their  presence  and  proportions  in 
compounds.  The  indiscriminate  adoption  of  matter,  without  examination,  has  been  uniformly  avoided, 
and  in  no  instance  has  any  formula  or  process  been  admitted  into  this  work,  unless  it  rested  on  some 
well-known  fact  of  science,  had  been  sanctioned  by  usage,  or  come  recommended  by  some  respectable 
authorityo 


TYNDALL.      Essays  on  the  Floating  Matter   of  the  Air,  in 

Relation  to  Putrefaction  and  Infection.    By  Prof.  John  Tyndall,  F.  R.  S. 
12mo.    Cloth,  $1.50. 

CONTENTS. — I.  On  Dust  and  Disease ;  II.  Optical  Deportment  of  the  Atmosphere  in  Eelation 
to  Putrefaction  and  Infection  ;  III.  Further  Eesearches  on  the  Deportment  and  Vitality  of  Putrefactive 
Organisms ;  IV.  Fermentation,  and  its  Bearings  on  Surgery  and  Medicine ;  V.  Spontaneous  Genera- 
tion ;   Appendix. 


"  Prof.  Tyndall' s  book  is  a  calm,  patient,  clear, 
and  thorough  treatment  of  all  the  questions  and 
conditions  of  nature  and  society  involved  in  this 
theme.  The  work  is  lucid  and  convincing,  yet  not 
prolix  or  pedantic,  but  popular  and  really  enjoy- 
able. It  is  worthy  of  patient  and  renewed  study." 
— Philadelphia  Times. 

"  The  matter  contained  in  this  work  is  not  only 
presented  in  a  very  interesting  way,  but  is  of  great 
value." — Boston  Journal  of  Commerce. 

"  The  germ  theory  of  disease  is  most  intel- 
ligently presented,  and  indeed  the  whole  work 
is  instinct  with  a  high  intellect." — Boston  Com- 
monwealth. 


"  In  the  book  before  us  we  have  the  minute  de- 
tails of  hundreds  of  observations  on  infusions  ex- 
posed to  optically  pure  air;  infusions  of  mutton, 
beef,  haddock,  hay,  turnip,  liver,  hare,  rabbit, 
grouse,  pheasant,  salmon,  cod,  etc. ;  infusions 
heated  by  boiling  water  and  by  boiling  oil,  some- 
times for  a  few  moments  and  sometimes  for  several 
hours,  and,  however  varied  the  mode  of  procedure, 
the  result  was  invariably  the  same,  with  not  even 
a  shade  of  uncertainty.  The  fallacy  of  spontane- 
ous generation  and  the  probability  of  the  germ 
theory  of  disease  seem  to  us  the  inference,  and  the 
only  inference,  that  can  be  drawn  from  the  results 
of  nearly  ten  thousand  experiments  performed  by 
Prof.  Tyndall  within  the  last  two  years." — Pitts- 
hurg  Telegraph. 


ULTZMANN".  Pyuria;  or,  Pus  in  the  Urine,  and  its  Treat- 
ment :  Comprising  the  Diagnosis  and  Treatment  of  Acute  and  Chronic 
Urethritis,  Prostatitis,  Cystitis,  and  Pyelitis,  with  especial  reference  to 
their  Local  Treatment.  By  Dr.  Robert  Ultzmann,  Professor  of  Genito- 
urinary Diseases  in  the  Vienna  Poliklinik.  Translated,  by  permission,  by 
Dr.  Waltee  B.  Platt,  F.  R.  C.  S.  (Eng.),  Baltimore.  12m o.  Cloth, 
11.00. 


"  Those  of  the  profession  who  are  familiar  with 
the  works  of  Prof.  Ultzmann  will  welcome  this 
translation  as  constituting  a  real  addition  to  our 
literature  on  genito-urinary  diseases.  It  can  not 
be  too  highly  recommended  to  the  attention  of  the 
profession,  not  only  on  account  of  its  scientific 
value,  but  also  for  the  many  practical  suggestions 
regarding  treatment  to  be  found  in  the  chapter  on 
Therapeutics.  The  translator  is  to  be  congratu- 
lated upon  the  excellent  manner  in  which  his  work 
has  been  accomplished.  The  book  is  neatly  and 
tastefully  got  up  by  the  publishers." — Maryland 
Medical  Journal, 

"  This  excellent  monograph  contains,  in  less 
than  one  hundred  pages,  a  complete  review  of  the 
conditions  that  give  rise  to  pus  within  the  urinary 


tracts.  Acute  and  chronic  urethritis,  prostatitis, 
cystitis,  and  pyelitis  are  discussed  in  turUj  with 
especial  reference  to  their  diiferential  diagnosis  and 
treatment.  As  a  result  of  observation  and  experi- 
ence, the  author  states  that  while  acute  urethritis 
can  only  be  cured  by  the  direct  application  of 
remedies  to  the  diseased  part,  other  forms  of  acute 
pyuria,  '  and  above  all  that  of  the  bladder  and  neck 
of  the  bladder,  ought  never  to  be  treated  locally, 
but  by  internal  medication  and  regulation  of  diet; 
while  in  chronic  pyuria  of  any  part  of  the  urinary 
tract  an  appropriate  local  treatment  takes  a  promi- 
nent place.'  The  remedies  and  methods  of  treat- 
ment that  have  been  used  with  most  success  by 
the  author  are  considered  in  detail  in  the  chapter 
on  the  Therapeutics  of  Polyuria."— i/e<Z«c«Z  Bul- 
letin. 


62 


D.  APPLETON  &   CO:S  ILLUSTRATED 


VAN  BUREN.  liectures  on  the  Principles  of  Surgery.  Deliv- 
ered at  the  Bellevue  IIos])ital  Medical  College.  By  the  late  W.  H.  Van 
BuREX,  M.  D.,  LL.  D.  Edited  by  Dr.  Lewis  A.  Stimson.  8vo.  588 
pages.     Cloth,  $4.00  ;  sheep,  85.00. 

"If  we  are  to  judge  of  the  interesting  style  by     position  as  a  teacher  of  surirery.     Dr.  Lewis  A. 

the  mere  rcadinor  of  these  lectures,  how  frreatiy     '-'^- ' »■„..-,  ,i  .,  i„  .^:„  .  i «.. ..i-. 

they  must  have  been  appreciated  by  those  who 
heard  tliem  bv  the  teacher  I  There  is  nothino-  dry 
or  prosy  in  tlieni.  The  illustrations  of  principles 
are  drawn  from  the  clinical  material  of  tlie  teacher, 
and  are  always  tresh  and  a  propns.  Past  and 
present  theories  are  compared  in  such  a  way  as  to 


btimson  has  conferred  a  lastiuir  benefit  upon  the 
profession  by  the  conscientious  dischartre  of  his 
duty  as  editor  of  the  late  Prof.  Van  Buren's  lecture 
notes.      As  a  tribute  to  the  memory   of  a  great 
American  surgeon,  and  as  an  invaluable  contribu- 
tion to  the  literature  of  the  subject.  Van  Buren's 
'  Lectures  on  the  Principles  of  Surgery '  will  find 
give  the  student  an  interest  in  the  work  of  older     an  honored  place  in  every  well-selected  medical 
pathologists,  and  to  point  out  progress  made,  with-     library."  —  t'hieugo    Medical    Journal    and    Ex- 
out  wearying  him  with  a  dry  narration  at  a  time     arniner. 
when  he  is  not  able  to  comprehend  tlie  underlying 
philosophy.      Dr.  Van   Buren's   popularity   as    a 
teacher  can  be  easily  understood  from  a  study  of 
this  volume.     His  manner  is  vivacious,  his  matter 
select,  and  his  fullness  of  knowledtre  easily  dis- 
cernible.    He  writes  like  one  in  autfiority,  full  of 
enthusiasm,  and  posse.-sed  of  the  ^kill  of  impart- 
ing to  students  just  that  sort  of  knowledge  best 
suited  to  their  tuture  intellectual   growth.      The 
work  is  handsomely  printed,  with  full-faced,  clear 
type  and  leaded  lines,  and  is  in  every  way  a  credit 
to  the  publishers." — A'orth  CavoUnn  Mtd.  Jourual. 

"  Dr.  Van  Buren,  for  a  period  of  tijirty-tive 
years  prior  to  his  death,  occupied  a  phenomenal 


"  This  book  is  the  teaching  of  an  experienced 
surgeon,  of  one  who  knew  of  what  he  was  saying, 
and  from  personal  observation.  It  is  such  a  work 
on  surgery  that  the  general  practitioner  should 
consult  and  be  governed  by,  as  from  it  he  can  be 
advised  how  to  treat  and  manage  the  complications 
of  surgery.  Known  so  well  as  is  Dr.  Van  Bureu, 
we  can  neither  add  to  n^r  detract  from  what  he 
has  given  in  this  work  before  us.  It  has  been 
ably  edited  by  Dr.  Stimson.  and  we  advise  our 
readers  to  have  a  copy  of  it  in  their  libraries." — 
TTiirapei.itic  Gazette, 


VAN  BUREN.  Lectures  upon  Diseases  of  the  Rectum  and  the 
Surgery  of  the  Lower  Bowel.  Delivered  at  the  Bellevue  Hospital 
Medical  College.  By  W.  H.  Van  Burex,  M.  D.,  late  Professor  of  the  Prin- 
ciples and  Practice  of  Surgery  in  the  Bellevue  Hospital  Medical  College, 
etc.,  etc.  Second  edition,  revised  and  enlarged.  8vo.  412  pages.  With 
27  Illustrations  and  complete  Index.     Cloth,  83.00  ;  sheep,  84.00. 


Specimen  of  Illusteatiox. 


"  The  reviewer  too  often  finds  it  a  diffi- 
cult task  to  discover  points  to  praise,  in 
order  that  his  criticisms  may  not  seem  one- 
sided and  uuj ust.  These  lectures,  however, 
place  him  upon  the  other  horn  of  the 
dilemma,  viz..  to  find  somewhat  to  criticise 
severely  enough  to  clear  himself  of  the 
charge  of  indiscriminatintr  laudation.  Of 
course,  the  author  upholds  some  views 
which  contlict  with  other  authorities,  but 
he  substantiates  them  by  the  most  power- 
ful of  arguments,  viz.,  a  large  experience, 
the  results  of  which  are  enunciated  by  one 
who  elsewhere  siiows  that  he  can  appre- 
ciate, and  accord  the  due  value  to,  the  work 
and  experience  of  others." — Archives  of 
Medicine. 

"  The  present  is  a  new  volume  rather 
than  a  new  edition.  Both  its  size  and  ma- 
terial are  vastly  beyond  its  predecessor. 
The  same  scholarly  method,  the  same  calm, 
convincing  statement,  the  same  wise,  care- 
fully matured  counsel,  pervade  even"  para- 
graph. The  discnratbrt  and  dangers  of  the 
diseases  of  the  rectum  call  tor  greater  con- 
sideration than  they  usually  receive  at  the 
hands  of  the  profession." — Detroit  Lancet. 

'•  These  lectures  are  twelve  in  number, 
and  may  be  taken  as  an  excellent  epitome 
of  our  present  knowledee  of  the  diseases  of 
the  parts  in  question.  The  work  is  full  of 
practical  matter,  but  it  owes  not  a  little  of 
Its  value  to  the  original  thought,  labor,  and 


CATALOGUE  OF  MEDICAL   W0RK8. 


53 


suggestions  as  to  the  treatment  of  disease,  which 
always  characteiize  the  productions  of  the  pen  of 
Dr.  van  Buren." — Philadelphia  Medical  Times. 

"  The  most  attractive  feature  of  the  work  is 
the  plain,  common-sense  manner  in  which  each 
subject  is  treated.  The  author  has  laid  down  in- 
structions for  the  treatment,  medicinal  and  opei-a- 
tive,  of  rectal  diseases  in  so  clear  and  lucid  style  as 
that  any  practitioner  is  enabled  to  follow  it.  The 
lar^e  and  successful  experience  of  the  distinguished 
author  in  this  class  of  diseases  is  sufficient  of  itself 
to  warrant  the  high  character  of  the  book." — Nash- 
ville Journal  of  Medicine  and  Surgery. 

"...  We  have  thus  briefly  tried  to  give  the 
reader  an  idea  of  the  scope  of  this  work :  and  the 
work  is  a  good  one — as  good  as  either  AUingham's 
or  Curling's,  with  which  it  will  inevitably  be  com- 
pared. Indeed,  we  should  have  been  greatly  sur- 
prised if  any  work  from  the  pen  of  Dr.  Van  Buren 
had  not  been  a  good  one ;   and  we  have  to  thank 


him  that  for  the  first  time  we  have  an  American 
text-book  on  this  subject  which  equals  those  that 
have  so  long  been  the  standards."— A'lsw  York 
Medical  Journal. 

"  Mere  praise  oi  a  book  like  this  would  be 
superfluous — almost  impertinent.  The  author  is 
well  known  to  the  profession  as  one  of  our  most 
accomplished  surgeons  and  ablest  scientific  men. 
Much  is  expected  of  him  in  a  book  like  the  one  be- 
fore us,  and  those  who  read  it  will  not  be  disap- 
pointed. It  will,  indeed,  be  widely  read,  and  in  a 
short  time  take  its  place  as  the  standard  American 
authority."— jS'^.  Louis  Courier  of  Medicine. 

"  Taken  as  a  whole,  the  book  is  one  of  the 
most  complete  and  reliable  ones  extant.  It  is  cer- 
tainly the  best  of  axr^  similar  work  from  an 
American  author.  It  is  handsomely  bound  and 
illustrated,  and  should  be  in  the  hands  of  every 
practitioner  and  student  of  medicine." — Louisville 
Medical  Herald. 


VOGEL.      A  Practical  Treatise  on  the  Diseases  of  Children. 

Third  American  from  the  eighth  German  edition.  Revised  and  enlarged. 
Illustrated  by  Six  Lithographic  Plates.  By  Alfred  Vogel,  M.  D,,  Pro- 
fessor of  Clinical  Medicine  in  the  University  of  Dorpat,  Russia.  Trans- 
lated and  edited  by  H.  Raphael,  M.  D.,  late  House  Surgeon  to  Bellevue 
Hospital ;  Physician  to  the  Eastern  Dispensary  for  the  Diseases  of  Chil- 
dren, etc.,  etc.     8vo.     640  pages.     Cloth,  14.50  ;  sheep,  15.50. 

"' Vogel' s  Treatise  on  Diseases  of  Children' 
has  a  world-wide  reputation,  having  appeared  in 
theEussian,  German,  Dutch,  and  English  languages. 
This  is  a  deserved  success,  for  it  is  a  book  admira- 
bly adapted  to  the  wants  both  of  the  practitioner 
and  student.  The  present  edition  is  brought  well 
up  to  the  present  state  of  pathological  knowledge  ; 
it  is  complete  without  prolixity,  and  the  book  bears 
upon  its  pages  the  evidence  of  the  work  of  a  skill- 
ful and  experienced  clinical  practitioner.  .  .  .  We 
would  most  heartily  commend  the  book  as  oae  of 
the  most  valuable  upon  the  subject,  and  indeed  few 
physicians  can  afl'ord  to  forego  the  advantages  to 


be  derived  from  the  possession  of  this  work." — 
Buffalo  Medical  and  /Surgical  Journal. 

"  This  is  indeed  a  valuable  addition  to  the  lit- 
erature of  Psediatrics.  ...  In  this  latest  edition  (3d 
American)  much  has  been  added  to  the  chapters 
on  Artificial  Nutrition,  a  subject  of  deep  interest 
to  the  practitioner,  on  Difficulties  of  Dentition,  and 
on  Nervous  Diseases  of  Children.  .  .  .  This  alone 
should  be  worth  the  price  of  the  book,  as  the  treat- 
ment of  diseases  of  children  is  too  much  after  the 
stereotyped  fashion  of  the  last  century." — DanieVs 
Texas  Medical  Journal. 


VOIi   ZEISSIi.      Outlines  of  the  Pathology  and  Treatment  of 
Syphilis  and  Allied  Venereal   Diseases.     By  Hermann  von 

Zeissl,  M.  D.,  late  Professor  at  the  Imperial-Royal  University  of  Vienna. 
Second  edition,  revised  by  Maximilian  von  Zeissl,  M.  D.,  Privat-Docent 
for  Diseases  of  the  Skin  and  Syphilis  at  the  Imperial-Royal  University  of 
Vienna.  Authorized  edition.  Translated,  with  I^otes,  by  H.  Raphael, 
M.  D.,  Attending  Physician  for  Diseases  of  the  Genito-Urinary  Organs 
and  Syphilis,  Bellevue  Hospital  Out-patient  Department,  etc.  8vo,  402 
pages.     Cloth,  14.00;  sheep,  15.00. 


"  We  regard  the  book  as  an  excellent  text-book 
for  student  or  physician,  and  hope  to  hear  of  its 
adoption  as  such.  In  therapeutic  detail,  the  rec- 
ommendations are  all  good."  —  Virginia  Medical 
Monthly. 

"  It  is  scarcely  necessary  to  refer  to  the  talented 
author  of  the  above-named  work,  since  his  life-long 
labor  as  a  teacher  and  writer  upon  venereal  diseases 
has  made  him  known  and  quoted  wherever  these 
afiections  exist  and  are  treated." — Polyclinic. 

"  It  is  a  most  thorough  and  practical  manual, 
and  translator  and  publisher  both  have  done  well 


in  their  respective  capacities  in  thus  issuing  it." — ■ 
Medical  Press  of  Western  Neio  York. 

"The  book  is  a  most  excellent  one  in  every  re- 
spect, and  the  translator  has  done  his  work  well." 
— Columhus  Medical  Journal. 

"  The  chapter  on  Gonorrhoea  is  masterly  and 
concisely  written.  ...  A  line  of  treatment  pru- 
dent, concise,  and  thorough  is  advised,  and  in  the 
choice  and  uses  of  the  mercurial  salts  shows  good 
reasoning,  clear  observation,  and  a  clinically  ex- 
perienced judgment."  —  Alabama  Medical  and 
Surgical  Journal. 


54  D.  APPLET  OX  &    CO:S  ILLUSTRATED 

"Medical  science  suflFered  a  severe  loss  when,  nal  some  seven  months  before  the  father's  death, 

in   September,  1884,    Hermann   von   Zeissl   died.  It  is  a  masterly  treatise  and  thoroughly  practical. 

Happily  for  us,  this  master  in  his  chosen  specialty  We  can  commend  it  to  all  wlio  are  interested  in 

haa  embodied  the  results  of  his  vast  experience  in  venereal  subjects.  .  .  .  Dr.  Eaphael  has  made  a 

a  text-book  on  syphilis  and  venereal  diseases  and  smooth  and  readable  translation,  and  has  added 

published  it  some  years  before  his  death.     The  much  valuable  matter  to  the  book,  adapting,'  it  to 

book  now  before  us   Ls   a  second  edition  of  the  the  use  of  American  physicians.     The  chapter  on 

former  book,  revised  and  in  large  part  rewritten  Gallopinfr  Syphilis  is  entirely  by  him." — Tlie  itew 

by  Maximilian  von  Zeissl,  and  issued  in  the  origi-  York  Medical  Journal. 

WAGNER.  A  Hand-Book  of  Chemical  Technology.  By  Rudolph 
Wagxkr,  Ph.  D.,  Professor  of  Chemical  Technology  at  the  University  of 
"NVurzburg.  Translated  and  edited,  from  the  eighth  German  edition,  Avith 
Extensive  Additions,  by  "William  Crooks,  F.  R.  S.  "With  336  Illustra- 
tions.    8vo.     761  pages.     Cloth,  S5.00. 

Under  the  head  of  Metallurgic  Chemistry,  the  latest  methods  of  preparing  iron,  cobalt,  nickel,  cop- 
per, copper-salts,  lead  and  tin  and  their  salts,  bismuth,  zinc,  zinc-salts,  cadmium,  antimony,  arsenic, 
mercury,  platinum,  silver,  gold,  manganates,  aluminium,  and  magnesium,  are  described.  The  various 
appUcations  of  the  voltaic  current  to  electro-metallurgy  follow  under  this  division.  The  preparation  of 
potash  and  soda  salts,  the  manufacture  of  sulphuric  acid,  and  the  recovery  of  sulphur  from  soda  waste, 
of  course  occupy  prominent  places  in  the  consideration  of  chemical  manufactures.  It  is  diflBcult  to 
overestimate  the' mercantile  value  of  Mond's  process,  as  well  as  the  many  new  and  important  applica- 
tions of  bisulphide  of  carbon.  The  manufacture  of  soap  will  be  found  to  include  much  detail.  The 
technology  of  glass,  stone-ware,  limes,  and  mortars  will  present  much  of  interest  to  the  builder  and 
ensrineery*  The  technology  of  vegetable  fibers  has  been  cousidered  to  include  the  preparation  of  flax, 
hemp,  cotton,  as  well  a.s  paper-making;  while  the  application  of  vegetable  products  will  be  found  to 
ineluae  sugar- boiling,  wine-  and  beer-brewing,  the  distillation  of  spirits,  the  baking  of  bread,  the 
preparation  of  vinegar,  the  preservation  of  wood,  etc. 

jDr.  Wagner  gives  much  information  in  reference  to  the  production  of  potash  from  sugar- residues. 
The  use  of  baryta-salts  Ls  also  fiiUy  described,  as  well  as  the  preparation  of  sugar  from  beet-roots. 
Tanning,  the  preservation  of  meat,  "milk,  etc.,  and  the  preparation  of  phosphorus  and  animal  charcoal, 
are  considered  as  belonging  to  the  technology  of  animal  products.  The  preparation  of  materials  for 
dyeing  has  necessarily  required  much  space ;  'while  the  final  sections  of  the  book  have  been  devoted 
to  the  technology  of  heating  and  illumination. 

WALTON.  The  Mineral  Springs  of  the  United  States  and 
Canada,  with  Analyses  and  Notes  on  the  Prominent  Spas  of  Europe  and 
a  List  of  Sea-side  Resorts.  By  George  E.  Waltox,  M.  D.,  Lecturer  on 
Materia  Medica  in  the  Miami  Medical  College,  Cincinnati.  Second  edi- 
tion, revised  and  enlarged.     12rao.      414  pages.     With  Maps.     S2.00. 

The  author  has  given  the  analyses  of  all  the  springs  in  this  country,  and  those  of  the  principal  Eu- 
ropean spas,  reduced  to  a  uniform  standard  of  one  wine- pint,  so  that  they  may  readily  be  compared. 
He  has  arranged  the  .springs  of  America  and  Europe  in  seven  distinct  classes,  and  described  the  diseases 
to  which  mineral  waters  are  adapted,  with  references  to  the  class  of  waters  applicable  to  the  treatment ; 
and  the  peculiar  characteristics  of  each  spring  as  near  as  known  are  given — also  the  location,  mode  of 
access,  and  post-oflice  address  of  every  springy  are  mentioned.  In  addition,  he  has  described  the  various 
kinds  of  baths  and  the  appropriate  use  of  them  in  the  treatment  of  disease. 

"  Precise  and  comprehensive,  presenting  not  advise  their  use  a-s  intelligently  and  beneficially 
only  reliable  analyses  of  the  waters,  but  their  as  they  can  other  valuable  alterative  agents." — 
therapeutic  value,  so  that  physicians  can  hereafter    Sanitarian. 

WEBBER.  A  Treatise  on  Nervous  Diseases  :  Their  Symptoms  and 
Treatment.  A  Text-Book  for  Students  and  Practitioners.  By  S.  G.  "Web- 
ber, M.  D.,  Clinical  Instructor  in  Nervous  Diseases,  Harvard  Medical 
School  ;  Visiting  Physician  for  Diseases  of  the  Nervous  System  at  the 
Boston  City  Hospital,  etc.  8vo.  415  pages.  15  Illustrations.  Cloth, 
^3.00. 

"  The  book  before  us  is  especially  adapted  to  the  best  interests  of  his  patient.  Dr.  Webber  has 
the  needs  of  the  general  practitioner  who,  thouirh  not  written  for  the  specialist,  but  for^the  student 
conscious  of  his  inability  to  discern  and  trace  the  and  general  practitioner,  who  will  find  in  his  hook 
nervous  element  in  the  cases  under  his  care,  realizes  what  they  most  need  for  the  diagnosis  and  treat- 
very  fully  that  this  inability  is  not  consonant  with  ment  of  the  diseases  as  they  present  themselves  in 


CATALOGUE  OF  MEDICAL  WORKS. 


general  practice.  His  style  is  very  readable  and 
lucid,  and  is  well  adapted  to  those  who  have  not 
specially  prepared  themselves  to  understand  the 
peculiar  language  of  the  more  advanced  neurolo- 
^ffist.  He  covers  very  completely  the  field  of  nerv- 
ous affections,  and  his  book  will  prove  a  very 
valuable  acquisition  to  the  library  of  the  iutelligent 
physician." — Medical  Age. 

"  The  beauty  and  usefulness  of  the  book  are 
much  enhanced  by  the  fact  that  it  is  not  loaded 
down  with  references  to  other  authors,  but  pro- 
ceeds in  au  original  manner  to  sum  up  all  that  is 
known  to  the  present  day  upon  the  subjects 
treated.     Taking  the  book  as  a  whole,  it  is  one  of 


the  best  we  have  seen  in  many  a  day." — Texas 
Co  urier-  Record. 

"...  The  man  with  but  a  single  book  on 
nervoas  diseases  can  not  do  better  than  to  buy  it. 
One  feature  in  it  which  merits  especial  praise  is'  the 
admirable  bibliographies  i^refixed  to  each  chapter." 
— Journal  of  jVervous  and  Mental  Disease. 

"...  We  have  no  hesitation  in  recommending 
this  admirable  little  book  to  students  and  prac- 
titioners alike." — New  Torh  Medical  Journal. 

"  .  .  .  The  anatomy  and  physiology  of  the 
brain  are  treated  of  in  an  exceptionally  clear  and 
concise  manner." — Denver  Medical  Times. 


WEEKS.  A  Text-Book  of  Nursing.  For  the  Use  of  Training-Schools, 
Families,  and  Private  Students.  Compiled  by  Clara  S.  Weeks,  Graduate 
of  the  New  York  Hospital  Training-School ;  Superintendent  of  Training- 
School  for  Nurses,  Paterson,  New  Jersey.  12mo.  366  pages.  With  13 
Illustrations.  Questions  for  Review  and  Examination,  and  Vocabulary  of 
Medical  Terms.     11.75. 


"This  book,  in  twenty-three  chapters,  commu- 
nicates a  large  quantity  of  useful  infoi-mation  in  a 
form  intelligible  to  the  public.  It  is  well  written, 
remarkably' correct,  suflBciently  illustrated,  and 
handsomely  printed.  The  amount  of  technical 
skill  and  knowledge  required  of  nurses  at  the 
present  day  makes  the  use  of  some  text-book  in- 
dispensable.   To  those  who  need  such  a  work  we 


can  speak  approvingly  of  its  design,  scope,  and 
execution." — Philadelphia  Medical  Times. 

"  This_  is  an  admirably  written  book,  and  is  full 
of  those  important  practical  details  necessary  for 
the  medical  and  surgical  nurse.  In  fact,  it  could 
be  read  with  profit  "by  every  medical  student  and 
young  practitioner." — Medical  Record. 


WORCESTER.    Monthly  Nursing. 

of  the  Massachusetts  Medical  Society. 
$1.25. 


By  A.  Worcester,  M.  D.,  Fellow 
Second  edition,  revised.     Cloth, 


"  This  is  the  very  best  little  book  it  has  been 
our  pleasure  to  read  for  many  a  day.  As  its  title 
indicates,  it  contains  directions  to  and  outlines  the 
duties  to  the  nurse  during  the  first  month  after 
childbirth.  The  author  does  this  in  a  thorough, 
complete,  and  practical  way.  His  language  is 
pointed,  and  his  style  has  made  the  subject  in- 
teresting. Though  written  for  the  student-nurse, 
the  physician  will  find  many  useful  suggestions 
in  it,  and  fathers  and  mothers  will  be  made  bet- 

WYETH.  A  Text-Book  on  Surgery :  General,  Operative,  akd 
Mecha^tical.  By  Johx  A.  Wteth,  M.  D.,  Professor  of  General  and 
Genito-Urinary  Surgery  in  the  New  York  Polyclinic  ;  Visiting  Surgeon  to 
Mount  Sinai  Hospital,  etc.  Second  edition,  revised  and  enlarged.  Sold 
by  Subscription.     Cloth,  $7.00  ;  sheep,  $8.00  ;  half  morocco,  $8.50. 


ter  parents   by  its   perusal." — Memphis  Medical 
Monthly, 

"  The  author  has  succeeded  in  presenting  a  very 
excellent,  readable,  and  practical  little  work,  setting 
forth  the  principles  of  action  in  the  order  in  which 
the  nurse  will  need  them,  and  telling  what  kind  of 
service  the  physician  and  the  patient  nave  the  right 
to  expect  from  the  monthly  nurse." — College  and 
Clinical  Record. 


"  Dr.  "Wyeth  has  succeeded  in  compressing  into 
less  than  eight  hundred  octavo  pages  a  more  or  less 
complete  description  of  almost  every  surgical  dis- 
ease and  condition,  including  those  of  the  eye  and 
ear.  The  chapter  on  the  ligature  of  arteries  is  un- 
doubtedly the  best  in  the  book,  the  plates  being 
beautifully  colored  and  nearly  all  original.  The 
subjects  of  genito-urinary  disease  and  orthopsedic 
surgery  are  likewise  fully  discussed,  and  show  an 
intimate  knowledsre  thereof  on  the  part  of  the 
author.  The  work  throughout  is  copiously  illus- 
trated, and  may  be  relied  upon  as  a  fair  guide  to 
both  the  general  practitioner  and  student." — 
Canada  Medyical  and  Surgical  Journal. 

"  A  modem  text-book  on  surgery,  provided  it 
professes  to  give  within  a  moderate  compass  a 
satisfactory  account  of  the  general  range  of  sur- 


gery, is  valuable  to  the  general  practitioner  in  pro- 
portion as  it  makes  details  plain  and  clearly  pre- 
sents their  underlying  pi-inciples.  Gauging  it  on 
this  basis,  we  are  convinced  that  Dr.  Wyeth's  work 
will  speedily  take  a  prominent  place  in  the  esteem 
of  the  profession.  ...  In  particular,  we  woiild 
commend  the  care  that  has  been  bestowed  on  the 
important  matters  of  surgical  dressines,  bandag- 
ing, and  the  like.  These  details  lie  at  the  very 
foundation  of  success  in  surgical  practice,  and  too 
much  attention  can  scarcely  oe  given  to  tliem  in  a 
text-book.  The  appearance  of  the  book  is  in  the 
highest  degi'ee  creditable  to  the  publishers ;  the 
print  is  clear,  the  paper  is  excellent,  and  the  illus- 
trations, which  are  numerous  and  nearly  all  origi- 
nal, are  among  the  best  of  their  class  that  we  have 
seen.  They  include  quite  a  number  printed  in 
colors." — New  York  Medical  Journal. 


56 


D.  APPLETON  &    CO:S  ILLUSTRATED 


Specimen  of  Illubtkation. 


"...  The  writint'  of  a  surgery  that  .shall  be 
new  in  its  matter  is  simply  impossible.  But  the 
author  has  evidently  grasped  and  digested  the 
facts  of  surgery  as  known  to-day,  and,  after  find- 
ing those  which  best  suited  his  practical  work, 
presented  them  to  his  professional  fellow- workers. 
Others  would  write  a  different  work  from  the  same 
data,  because  no  two  minds  run  in  the  same  direc- 
tion. But  in  this  sense  this  work  is  original.  In 
this  sense  it  will  be  found  interesting  and  instruct- 
ive to  all  students  and  professional  men.  The 
chapter  on  the  Litigation  of  Arteries  is  worth  the 
price  of  the  entire  work.  The  illustrations  are 
superb,  showing  in  color  the  parts  to  be  met  with 
in  the  reaching  of  arteries  in  every  portion  of  the 
body.  Quite  as  important  and  as  beautifully  illus- 
trated is  the  chapter  on  amputations.  He  who, 
Eossessing  proper  anatomical  knowledge,  could  not 
y  the  directions  here  given  perform  these  ampu- 
tations, should  be  convinced  that  he  had  missed 
his  calling." — American  Lancet. 


"  As  a  specimen  of  typographical 
and  book-makers'  work  it  is  unex- 
ceptionable. It  is  one  of  the  hand- 
somest works  ever  published,  is 
profusely  and  beautifully  illustrated, 
having  771  engravings,  of  which 
about  fifty  are  colored,  and  is  printed 
in  large  type  on  heavy  paper.  Nor, 
when  we  have  praised  the  mechani- 
cal work  of  the  book,  have  we  given 
all  of  its  merits.  It  is  undoubtedly 
a  useful  and  convenient  manual  of 
surgery.  The  author  has  kept  him- 
self thoroughly  posted  in  the  present 
literature  of  his  profession,  and  has 
incorporated  in  his  book  nearly  all 
of  the  latest  achievements  and  no- 
tions in  surgery.  We  believe  the 
book  to  be  the  production  of  a  good 
and  conscientious  surgeon,  and  can 
safely  recommend  it  to  the  profes- 
sion."— Medical  Herald. 

"The  perusal  of  this  book  by 
any  one  interested  in  surgery  can 
not  fail  to  afford  both  pleasure  and 
instruction.  .  .  .  The  illustrations 
constitute  a  special  feature,  for  they 
are  used  unsparingly  throughout  the 
entire  work,  and  are  of  a  very 
superior  order  of  merit.  .  .  .  The 
book  is  well  written,  fully  up  with 


the  present  status  of  surgery,  is  a  credit  alike  to 
author  and  publishers,  and  would  be  very  cheap 
at  double  the  price  chartred  for  it.  It  affords  us 
pleasure  to  look  over  a  book  which  we  can  thus 
praise  without  stint,  knowing  that  we  can  say 
nothing  iu  excess  of  its  merits." — Southern  Clinic. 

"...  Its  readers  will  have  nothing  derived 
from  its  study  to  unlearn.  Its  teachings  are  the 
accepted  ones  of  to-day,  while  within  its  nearly 
800  pages  we  have  found  but  very  few  superfluous 
.sentences.  ...  In  conclusion,  we  may  say  that  the 
book  is  characterized  thoughout  by  good,  practical 
common-sense,  wide  research,  and  excellent  .iudg- 
ment  as  to  what  should  be  left  out  of,  as  well  as 
what  should  enter  into,  a  work  of  this  scope." — 
Canada  Lancet. 

"  Dr.  Wyeth  has  prepared  a  very  excellent  trea- 
tise on  general,  mechanical,  and  operative  surgery, 
.  .  .  The  work  ...  is  distinctly  what  it  claims  to 
be,  'A  Text-Book  on  General,  Operative,  and 
Mechanical  Surgery,'  carefully  prepared  and  fully 
up  to  all  the  modern  improvements  in  surgery." 
— A'ew  York  Medical  Times. 

"...  The  eminent  surgeon.  Dr.  Wyeth,  has 
here  presented  a  most  valuable  production. 
Though  styled  a  text-book,  it  is  admirably  adapted 
a-s  a  work  "of  reference  for  the  surgeon  and  practi- 
tioner, giving,  a.s  it  does,  the  recent  and  advanced 
views  upon  all  surgical  procedures.  ...  In  short, 
the  entire  book  evinces  the  work  of  a  raaster-mina 
and  a  superior  operator  in  surgery." — Southern 
Medical  Record. 

"  A  surgeon  who  has  in  his  library  such  works 
as  Agnew's,  Gross's,  Hamilton's,  Ashurst's,  Sys- 
tem, etc.,  may  think  that  he  needs  no  new  one, 
but  we  venture  the  opinion  that  if  he  sees  this 
work  he  will  buy  it.  The  first  thing  that  will 
attract  him  is  the  elegant  colored  illustrations — 
the  new  cuts  and  the"  perfect  press- work.  Then 
the  terseness  and  vigor  of  the  style  in  which  it  is 
written  will  delight  him,  and  a  more  complete  ex- 
amination will  convince  him  that  the  book  is  so 
full  of  meat  that  he  can  not  do  without  it." — Buf- 
falo Medical  and  Surgical  Journal. 

Specimen  of  Illustration. 


CATALOGUE   OF  MEDICAL   WORKS.  57 

WYLIE.  Reports.  Belle vue  and  Charity  Hospital  Reports  for  1870, 
containing  valuable  contributions  from  Isaac  E.  Tayloe,  M.  D.,  Austin 
Flint,  M.  D.,  Lewis  A.  Satre,  M.  D.,  William  A.  Hammond,  M.  D., 
T.  Gaillard  Thomas,  M.  D.,  Frank  H.  Hamilton,  M.  D.,  and  others. 
8vo.     415  pages.     Cloth,  84.00. 

"  These  institutions  are  the  most  important,  as  connected  with  them  are  acknowledged  to  be  among 

regards  accommodations  for  patients  and  variety  of  the  first  in  their  profession,  and  the  volume  is  an 

cases  treated,  of  any  on  this  continent,  and  are  sur-  important  addition  to  the  professional  literature  of 

passed  by  but  few  in  the  world.     The  gentlemen  this  country." — Psychological  Journal. 

Journal  of  Cutaneous  and  Genito-TJrinary  Diseases.  Edited  by 
Prince  A.  Morrow,  A.  M,,  M.  D.,  and  John  A.  Fordtce,  M.  D.  Sub- 
scription price,  $2.50  per  annum;  single  copy,  25  cents. 

With  the  number  for  January,  1889,  this  Jomrnal  entered  upon  the  seventh  year  of  its  publication. 
The  history  of  the  Journal  has  been  one  of  progression,  and,  under  the  present  editorial  management, 
there  can  be  no  doubt  that  it  will  preserve  and  increase  the  reputation  already  established. 

Devoted  to  the  diseases  indicated  in  its  title,  the  Journal  will  be  conti-ibuted  to  by  the  most  eminent 
dermatologists  and  syphilographers  in  this  country.  Whenever  the  subject  requires  illustration,  wood- 
cuts or  chromo-hthographs  will  be  employed. 

Letters  from  Europe,  one  or  more  of  which  will  appear  in  each  issue  of  the  Journal,  will  keep  the 
reader  informed  of  the  advances  in  this  department  of  medicine  at  the  great  medical  centers,  Vienna, 
Berlin,  and  Paris. 

A  feature  of  tlie  Journal  will  be  the  publication  of  abstracts  of  translations  of  notable  papers  and 
selections  from  foreign  journals. 

Due  prominence  ^\-ill  be  given  to  Society  Transactions,  including  papers  read  and  the  discussions  had 
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INDEX 


Abortion. 

PAGE 

Thomas.     Lectures  on  Abortion 50 

Anatomy. 

Chauveau.  The  Comparative  Anatomy  of  the 
Domesticated  Animals 10 

Huxley.  Tha  Anatomy  of  Vertebrated  Ani- 
mals    26 

Eanney.  The  Applied  Anatomy  of  the  Nerv- 
ous System 38 

Tracy.  The  Essentials  of  Anatomy,  Physiolo- 
gy, and  Hygiene 50 

Bacteriology. 

Hueppe.  The  Methods  of  Bacteriological  In- 
vestigation    25 

Brain. 

Bastian.     The  Brain  as  an  Organ  of  Mind 4 

Corning.     A  Treatise  on  Brain  Exhaustion 11 

Hammond.    A  Treatise  on  Insanity 22 

Luys.     The  Brain  and  its  Functions 32 

Smith.    Diseases  of  Memory 47 

Chemistry. 

Johnston.     The  Chemistry  of  Common  Life. . .  26 

Eoscoe  and  Schorlemmer.  A  Treatise  on 
Chemistry 40 

Wagner.  A  Hand-book  of  Chemical  Tech- 
nology   54 

Wislicenus.  Adolph  Strecker's  Short  Text- 
book of  Organic  Chemistry 48 

Children's  Diseases. 

Steiner.     Compendium  of  Children's  Diseases.  47 

Vogel.  A  Practical  Treatise  on  the  Diseases 
of  Children 53 

D  ernxatology. 

Neumann.     Hand-book  of  Skin  Diseases 34 

Piffard.     A  Practical   Treatise  on  Diseases  of 

the  Skin 36 

Eobinson.     A  Manual  of  Dermatology 40 

Shoemaker.     A  Text-book  of  Diseases  of  the 

Skin 44 


Diagnosis. 

PAGE 

Burt.  Exploration  of  the  Chest  in  Health  and 
Disease 9 

Dictionaries. 

Campbell.     The  Language  of  Medicine 9 

Foster.     An  Illustrated  Encyclopsedic  Medical 

Dictionary 16 

Quain.    A  Dictionary  of  Medicine 37 

Ear. 

Gruber.  A  Text-Book  of  the  Diseases  of  the 
Ear 22 

Pomeroy.  The  Diagnosis  and  Treatment  of 
Diseases  of  the  Ear 36 

Em  ergen  cies. 

Doty.  A  Manual  of  Instruction  in  the  Prin- 
ciples of  Prompt  Aid  to  the  Injured 12 

Howe.    Emergencies,  and  How  to  Treat  them.  25 

Eye. 

Loring.     A  Text-book  of  Ophthalmoscopy 30 

Genito-  Urinary  Diseases. 

Keyes.     A  Practical  Treatise  on  the  Surgical 

Diseases  of  the  Genito-Urinary  Organs 27 

Keyes.     The  Tonic  Treatment  of  Syphilis 28 

Von  Zeissl.  Outlines  of  the  Pathology  and 
Treatment  of  SyphOis  and  Allied  Venereal 
Diseases 53 

Gynsecology. 

Jones.  Practical  Manual  of  Diseases  of  Women 
and  Uterine  Therapeutics 26 

Schultze.  The  Pathology  and  Treatment  of 
Displacements  of  the  Uterus 43 

Skene.    A  Test-book  on  the  Diseases  of  Women  45 

Health. 

Billings.     The  Eelatiou  of  Animal  Diseases  to 

the  Public  Health . .    5 

Down.    Health  Primers 13 

McSheny.     Health,  and  How  to  Promote  it. . .  33 

Eichardson.     A  Ministry  of  Health 39 

Smith.      Health 46 


60 


INDEX.— (  Continued.) 


Health  Resorts. 

PAGE 

Bennet.  Winter  and  Spring  on  the  Shores  of 
the  Mediterranean 5 

Walton.  The  Mineral  Springs  of  the  United 
States  and  Canada 54 


Heart. 

Bramwell.     Diseases  of  the  Heart  and  Thoracic 
Aorta 6 


Materia  Medica  and  Therapeutics. 

Bartholow.  On  the  Antagonism  between  Medi- 
cines and  between  Eemedies  and  Diseases.*   2 

Bartholow.  Treatise  on  Materia  Medica  and 
Therapeutics 3 

Castio.  Elements  of  Therapeutics  and  Prac- 
tice according  to  the  Dosimetric  System .   .  10 

Evetzky.  The  Physiological  and  Therapeutical 
Action  of  Ergot 14 

Harvey.     First  Lines  of  Therapeutics. .    24 

Pereira.  Elements  of  Materia  Medica  and 
Therapeutics 36 

Medicine. 

Bartholow.      A    Treatise    on   the   Practice   of 

Medicine 1 

Carter.     Elements  of  Practical  Medicine 10 

FJint.     Medicine  of  the  Future 16 

Legg.      On   the   Bile,   Jaundice,    and   Bilious 

Diseases 29 

Niemeyer.  A  Text-book  of  Practical  Medi- 
cine     34 

Stone.    Elements  of  Modern  Medicine 48 

Striimpell.     A  Text-book  of  Medicine 49 


Microscopy. 

Friedlaender.     The  Use  of  the  Microscope  in 

Clinical  and  Pathological  Examinations. . .   18 
Peyer.     An  Atlas  of  Clinical  Microscopy 36 

Nervous  Diseases. 

Bastian.      Paralyses:    Cerebral,   Bulbar,   and 

Spinal 4 

Bastian.    Paralysis  from  Brain  Disease 4 

Hammond.     A  Treatise  on  the  Diseases  of  the 

Nervous  System 23 

Hammond.     Clinical  Lectures  on  Diseases  of 

the  Nervous  System 22 

Stevens.     Functional  Nervous  Diseases 47 

Webber.     A  Treatise  on  Nervous  Diseases 54 


Nursing. 

PAGE 

Nightingale.     Notes  on  Nursing 35 

Weeks.     A  Text-book  of  Nursing 55 

Worcester.    Monthly  Nursing 55 

Obstetrics. 

Barker.     The  Puerperal  Diseases 1 

Elliot.     Obstetric  Clinic 13 

Lusk.     The  Science  and  Art  of  Midwifery 31 

Schroeder.     A  Manual  of  Midwifery 43 

Simpson.  The  Posthumous  Works  of  Sir 
James  Y.  Simpson 45 

Orthopaedics. 

Little.  Medical  and  Surgical  Aspects  of  In- 
Knee 30 

Poore.     Osteotomy  and  Osteoclasis 37 

Sayre.  A  Practical  Manual  on  the  Treatment 
of  Club- Foot 41 

Sayre.  Lectures  on  Orthopedic  Surgery  and 
Diseases  of  the  Joints 42 


Ovaries. 

Peaslee.     Ovarian  Tumors. .. . 


35 


Pathology. 

Billroth.       General    Surgical    Pathology    and 

Therapeutics 6 

Frey.     The  Histology  and  Histo- Chemistry  of 

'Man 18 

Maudsley.     The  Pathology  of  Mind 82. 

Periodicals. 

Journal  of  Cutaneous  and  Geuito-Urinary  Dis- 
eases    57 

New  York  Medical  Journal 57 

Popular  Science  Monthly 58. 

Phthisis. 

Bennet.  On  the  Treatment  of  Pulmonary  Con- 
sumption       5 

Evans.  A  Hand-book  of  Historical  and  Geo- 
graphical Phthisiology 13 

Jaccoud.  The  Curability  and  Treatment  of 
Pulmonary  Phthisis 26 

Physiology. 

Carpenter.     Principles  of  Mental  Physiology. .  10 

Flint.     Text-book  of  Human  Physiology 14 

Flint.  The  Physiological  Eflfects  of  Severe  and 
Protracted  Muscular  E.xercise 16' 


mD'EX.— (Continued.) 


61, 


Maudsley.     The  Physiology  of  the  Mind 33 

Mills.     Text- book  of  Animal  Physiology 33 

Mills.     Text-book  of  Comparative  Physiology.  33 
Kosenthal.    General  Physiology  of  Muscles  and 
Nerves 41 

Rectum. 

Van  Buren.  Lectures  upon  Diseases  of  the 
Eectum  and  the  Surgery  of  the  Lower 
Bowel 52 

Surgery. 

Bryant.     A  Manual  of  Operative  Surgery 7 

Buck.     Contributions  to  Eeparative  Surgery. . .     8 
Corning.     Local  Anajsthesia  in  General  Medi- 
cine and  Surgery 12 

Davis.     Conservative  Surgery 12 

Garraany.     Operative  Surgery  on  the  Cadaver.  19 
Gerster.     The  Rules  of  Aseptic  and  Antiseptic 
Surgery 20 

Gross.     A  Practical  Treatise  on  Tumors  of  the 

Mammary  Gland 21 

Kingsley.     A  Treatise  on  Oral  Deformities 28 

Van  Buren.  Lectures  on  the  Principles  of 
Surgery 52 

Wyeth.     A  Text-book  on  Surgery 55 

Urinalysis. 

Flint.    Manual  of  Chemical  Examination  of  the 

Urine  in  Disease 15 

HofmannandUltzmann.    Analysis  of  the  Urine.  24 


Misc  ellan  eous. 

PAGE 

Barker.     On  Sea-Sickness i 

Combe.     The  Management  of  Infancy 11  . 

Cooley.     Cyclopaedia  of  Practical  Receipts 50 

Flint.     Medical  Ethics  and  Etiquette 16 

Flint.     The  Source  of  Muscular  Power 16 

Fothergill.      The   Diseases   of  Sedentary   and 

Advanced  Life „ .  .  17 

Fournier.     Syphilis  and  Marriage 18 

Gamgee.  Yellow  Fever  a  Nautical  Disease.. .  19 
Howe.     The  Breath,  and  the  Diseases  which 

give  it  a  Fetid  Odor 25 

Lettei-man.     Medical  Recollections  of  the  Army 

of  the  Potomac 30 

Markoe.      A    Treatise    on    Diseases    of    the 
Bones 32 

Maudsley.     Body  and  Mind 32 

Maudsley.      Responsibility     in     Mental    Dis- 
eases    32 

Oswald.     Physical  Education 35 

Richardson.     Diseases  of  Modern  Life 40 

Shears.     The  New  York  Medical  Journal  Visit- 
ing-List    43 

Sims.     The  Story  of  My  Life 45 

Smith.     On  Foods 46 

Tracy.    Hand-book  of  Sanitary  Information  for 
Householders 50 

Tyndall.     Essays  on  the  Floating  Matter  of  the 
Air 51 

Ultzmann.     Pyuria;  or,  Pus  in  the  Urine,  and 

its  Treatment   , ^  ,  51 

Wylie.     Hospitals 57 


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41.  Diseases  of  Memory:   An  Essay  in  the  Positive  Psychology.      By  Th.  Ribot,  author  of 

"Heredity."     $1.50. 

42.  Ants,   Bees,    and   Wasps.      A   Record   of   Observations   of   the   Habits   of   the   Social 

Hyraenoptera.     By  Sir  John  Lubbock,  Bart.,  F.  R.  S.,  D.  C.  L.,  LL.  D.,  etc.     $2.00. 

43.  Science  of  Politics.     By  Sheldon  Amos.     $1.75. 

44.  Animal  Intelligence.     By  George  J.  Romanes.     $1.76. 

45.  Man  before  Metals.     By  N.  Joly,  Correspondent  of  the  Institute.    With  148  Illustrations. 

$1.75. 

46.  The  Organs  of  Speech  and    their  Application    in   the    Formation  of  Articu- 

late Sounds.     By  G.  H.  von  Meyer,  Professor  in  Ordinary  of  Anatomy  at  the  University 
of  Ziirich.     With  47  Woodcuts.     $1.75. 

47.  Fallacies  :    A  View  of  Logic  from  the  Practical  Side.     By  Alfred  Sidgwick,  B.  A.,  Oxon. 

$1.75. 


^4  The  International  Scientific  Series — (Continued). 

48.  Origin  of  Cultivated  Plants.     By  Alphonse  de  Candolle.     $2.00. 

49.  Jelly-Fish,  Star-Fish,  and  Sea-Urchins.      Being   a   Research  on  Primitive   Nervous 

Systems.     By  George  J.  Romanes.     $1.75. 

50.  The  Common  Sense  of  the  Exact  Sciences.      By  the   late  William   Kingdon   Clif 

FORD.       $1.50. 

51.  Physical  Expression:    Its  Modes  and  Principles.      By  Francis  Warner,  M.  D.,  Assistant 

Piiysician,  and  Lecturer  on  Botany  to  the  London  Hospital,  etc.      With  51  Illustrations. 

ll.'ZS. 

52.  Anthropoid  Apes.     By  Robert  Hartmann,  Professor  in  the  University  of  Berlin.    With  63 

Illustrations.     $1.'75. 

53.  The    Mammalia    in    their    Relation    to    Primeval    Times.      By   Oscar  Schmidt. 

$1.50. 

54.  Comparative    Liiterature.      By   Hutcheson   Macaulay   Posnett,  M.  A.,  LL.  D.,  F.  L.  S., 

Barrister-at-Law ;    Professor  of  Classics  and  English  Literature,  University  College,  Auck- 
land, New  Zealand ;  author  of  "  The  Historical  Method,"  etc.     $1.75. 

55.  Earthquakes  and  other  Earth  Movements.     By  John  Milne,  Professor  of  Mining  and 

Geology  in  the  Imperial  College  of  Engineering,  Tokio,  Japan.     With  38  Figures.     fl.'ZS. 

56.  Microbes,    Ferments,    and    Moulds.      By  E.  L.  Trouessart.      With  10*7  Illustrations. 

11.50. 

57.  The  Geographical  and  Geological  Distribution   of  Animals.      By  Angelo  Heil- 

prin.     $2.00. 

58.  Weather.      A  Popular  Exposition  of  the  Nature  of  Weather  Changes  from  Day  to  Day. 

With  Diagrams.     By  Hon.  Ralph  Abercromby.     $1.75. 

59.  Animal  Magnetism.      By  Alfred  Binet  and  Charles  Fere,  Assistant  Physician  at  the 

Salp^triere.     $1.50. 

60.  International  Law,  with  Materials  for  a  Code  of  International  Law.     By  Leone  Levi,  Pro- 

fessor of  Common  Law,  King's  College.     $1.50. 

61.  The  Geological  History  of  Plants.     \\\i\\  Illustrations.      By  Sir  J.  William  Dawson, 

LL.D.,  F.R.S.     $1.75. 

62.  Anthropology.      An  Introduction  to  the  Study  of  Man  and  Civilization.     By  Edward  B. 

Tylor,  D.  C.  L.,  F.  R.  S.     IHustrated.     $2.00. 

63.  The  Origin  of  Floral  Structures,  through  Insect  and  other  Agencies.      By  the 

Rev.  George  Henslow,  M.  A.,  F.  L.  S.,  F.  G.  S.     With  88  Illustrations.     $1.75. 

64.  On  the  Senses,  Instincts,  and  Intelligence  of  Animals,  with   Special    Refer- 

ence to  Insects.     By  Sir  John  Lubbock.     With  over  100  Ilhistrations.     $1.75. 

65.  The  Primitive  Family  in  its  Origin  and  Development.     By  Dr.  C.  N.  Starcke,  of 

the  University  of  Copenhagen. 


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